
Class 
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COPYRIGHT DEPOSE 



THE 



READY REFERENCE HANDBOOK • 



OF 



DISEASES OF THE SKIN 



BY 



GEORGE THOMAS JACKSON, M.D. 

LATE PROFESSOR OF DERMATOLOGY, COLLEGE OF PHYSICIANS AND SURGEON! 
NEW YORK: CONSULTING DERMATOLOGIST TO THE NEW YORK INFIRMARY FOR 
WOMEN AND CHILDREN; MEMBER OF THE AMERICAN DERMATOLOGICAL 
. ASSOCIATION AND NEW YORK DERMATOLOGICAL SOCIETY, ETC. 



WITH 115 ILLUSTRATIONS AND 6 PLATES 



SEVENTH EDITION, THOROUGHLY REVISED 




LEA & FEBIGER 

NEW YORK AND PHILADELPHIA 
1914 






Entered according to the Act of Congress, in the year 1914, by 

LEA & FEBIGER, 
in the Office of the Librarian of Congress. All rights rooorvod 



MAY -2 1914 



•CI.A869960 



PREFACE 



The aim of this book has always been to furnish 
students and practitioners with a comprehensive yet 
compact exposition of dermatology. The rate of growth 
of the subject is in a way reflected in some statistics of 
its increase in size. Its first edition in 1902 contained 
502 pages discussing 164 diseases. In this edition there 
are 726 pages describing 257 diseases. In spite of liberal 
pruning, rewriting, and the elimination of anything 
obsolete, this new issue is 32 pages longer than its 
predecessor. 

New sections have been added on acarodermatitis 
urticariodes, cutis verticis gyrata, eczema marginatum, 
eczematoid dermatitis, erythema figuratum perstans, gan- 
gosa, granuloma coccidioides, ground itch, hemisporosis, 
keratodermia gonorrhoica, leukemia cutis, lichenification, 
lichen nitidus, lichen planus sclerosus et atrophicus, and 
trypanosomiasis. Many of the old sections have been 
entirely rewritten. 

The author acknowledges with thanks his indebtedness 
to his friends: Dr. M. F. Engman, for an article on Vac- 
cines; to Dr. John A. Fordyce for one on Salvarsan; 
and to Dr. G. M. MacKee for one on the use of ar-rays. 
These gentlemen are so eminent in their respective fields 
that their contributions add greatly to the value of the 



IV PREFACE 

book. Hearty thanks are also due to Dr. H. Noguchi 
for pictures of Treponema pallida, and to Dr. H. Fox for 
some admirable photographs of cases. 

To the medical public the author expresses his appre- 
ciation for the kindly reception accorded the previous 
editions of the book and the hope that it will continue 
to render acceptable service. 

G. T. J. 
11 East Forty-eighth Street, 
New York. 



DISEASES OF THE SKIN. 



PART I. 

GENERAL CONSIDERATIONS. 

Anatomy and Physiology of the Skin. 

The skin varies in thickness in different regions of 
the body from J to 8 mm. It is composed of three 
distinct layers, namely : (1) the epidermis; (2) the derma, 
also named the cutis vera or corium; and (3) the subcuta- 
neous connective tissue. At all the orifices of the body 
lined with mucous membrane, the latter and the skin 
merge into each other. The appendages of the skin are 
the hair, the nails, the sebaceous and the sweat glands. 
This complicated structure is supplied with bloodvessels, 
lymphatics, and nerves. 

Epidermis. — The epidermis scarf skin, or cuticle, 
is composed of four layers, called strata, namely: (1) 
the stratum corneum; (2) the stratum lucidum; (3) the 
stratum granulosum; and (4) the stratum mucosum. 
Of these strata, the two that most concern us are the 
first and the last — that is, the stratum corneum and 
the stratum mucosum. The other layers of the skin 
may, for our present purpose, be regarded as simply 
transition-layers through which an epithelial cell passes 
on its developmental way to become a fully formed 
corneous cell. Each of the four strata of the epidermis 
2 



18 



DISEASES OF THE SKIN 



is divided again into layers, but these are of no prac- 
tical importance. The thickness of the epidermis varies 
from 0.25 to 1.65 mm., being thickest and most compact 



Fig. 1 




Vertical section through the skin. Diagrammatic. (After Heitzmann.) 



ANATOMY AND PHYSIOLOGY OF THE SKIN 19 

where it is subjected to the most pressure of intermittent 
character, as on the palms and soles. 

The stratum corneum, or horny layer, consists of a 
series of superimposed layers of flattened, elongated 
cells that increase in flatness from below upward. The 
upper layers are called scales. The cells of each layer 
are united to each other so much closer than the layer 
itself is united to those above or below it that when an 
effusion takes place into the stratum corneum a layer 
of cells in the affected area is raised and the fluid is 
found between two layers. The lamellated scaling met 
with in certain scaly diseases, such as dermatitis exfolia- 
tiva, in which great plates of scales are readily removable, 
is likewise due to this close relation between the cells 
of each layer. This stratum is largely a protective one, 
its compactness affording a fair degree of resistance to 
injury of the underlying, more succulent layers of the 
epidermis. 

The stratum mucosum, rete Malpighii, or mucous layer, 
is the deepest layer of the epidermis, and is seated upon 
the papillary layer of the corium. It is composed of 
several layers of cells, but may be considered as consist- 
ing of two chief layers, namely, the columnar epithe- 
lium and the prickle cells. The columnar epithelial cells 
are arranged perpendicularly to the papillae of the corium, 
while the prickle cells, which are polygonal in shape with 
spherical nuclei and with little filaments running out 
from their sides toward the neighboring cells, are arranged 
in strata over them. As the stratum granulosum, which 
lies above the stratum mucosum, is approached, the 
prickle cells become flatter, and finally lie with their 
long axis parallel to the general surface. The "granules" 
contain eleidin (Ranvier) and keratohyalin (Waldeyer), 
the former being a fluid and the latter a solid substance. 
The stratum mucosum is the most important stratum 
of the epidermis, and the seat of that most common of 
all skin diseases, eczema. From its lower part it sends 
down projections between the papillae of the corium, 



20 DISEASES OF THE SKIN 

which are called interpapillary projections. Most of 
the pigment of the skin is situated in the lower part of 
the stratum mucosum. As the upper part is approached, 
less and less pigment is found. The pigment itself is 
in tl^e form of granules and of diffused coloring matter. 
According to Unna, the pigment is found even in the 
upper part of this layer, while in pathological conditions 
it may be located in the corium. In the so-called colored 
races pigment is always found in the corium, and even 
the horny layer is stained. 

From this arrangement of the cells of the epidermis 
it will be seen that nutrient fluids can readily work 
upward from below by means of the little channels 
formed by the interlacing of the filaments running 
between the cells. 

The epidermis has no bloodvessels. It receives its 
nutrition entirely from the corium. Though there are 
no true lymphatics in the epidermis, there are abundant 
lymph spaces between the cells that take their place. 
Nerves of the non-medullated variety have been traced 
between the cells of the epidermis, and have been de- 
scribed by some histologists as entering into the cells 
to end at the nucleus, though not to enter it. The final 
distribution of the nerves in the epidermis is not yet 
fully determined. 

Corium. — The corium is composed of white fibrous 
and yellow connective tissue, disposed in horizontal 
bundles above and in oblique bundles below. It is a 
very dense and tough tissue, and is pierced in all direc- 
tions to allow of the passage of bloodvessels, lymphatics, 
sweat ducts, and nerves, and affords lodgement for the 
hair follicles and sebaceous glands. It contains a con- 
siderable amount of elastic fibers, especially in regions 
such as about the joints where there is more or less 
motion. The upper part has been named the pars 
papillaris, and the lower part the pars reticularis corii. 
From its upper part it sends off a vast number of pro- 
jections called papillw. These vary in length, being 



ANATOMY AND PHYSIOLOGY OF THE SKIN 21 

longest and most marked on the ends of the fingers and 
toes. The epidermis follows these projections and dips 
down between them. They are readily seen as parallel 
markings on the ends of the fingers. Over most of the 
body surface the papillae are but slightly raised, and 
merely give a wavy appearance to the upper edge of the 
corium when viewed under the microscope. As the 
lower part of the corium is reached the bundles of fibers 
are less closely crowded together, and becoming succes- 
sively looser, gradually pass over into the — 

Subcutaneous Connective Tissue. — This is a loose connec- 
tive tissue with large and small spaces in it, which are 
filled with adipose tissue. This consists of fat cells 
collected into lobulated masses that in some cases have 
about them a connective-tissue sheath. Each lobule 
is supplied with an afferent artery, a capillary plexus 
about it, and efferent veins. This part of the skin is 
called the panniculus adiposus, and is found everywhere 
except in the skin of the penis, scrotum, labia minora, 
eye-lids, pinna, and beneath the nails. It contributes 
to the roundness and beauty of the body, besides acting 
as a store-house for fuel against such times as the body 
cannot gain its proper nutriment from food, as in fevers. 
It also gives lodgement to the coil or sweat glands, and 
aids in protecting the underlying parts from injury. 
The lower ends of the deep hair follicles are also in this 
part of the skin. The subcutaneous tissue merges into 
the underlying fasciae of the muscles and the periosteum 
of the bones. Under the name of columnce adiposce, 
J. C. Warren has described certain prolongations of 
fatty tissue running up to the bases of the hair follicles. 
They are important in relation to the pathology of 
carbuncle. 

Bloodvessels. — The arteries which supply the skin 
come up from below to form a horizontal plexus in the 
subcutaneous tissue, from which the vessels proceed 
perpendicularly through the corium to form a second 
horizontal plexus just below the papillae. From the 



22 DISEASES OF THE SKIN 

lower plexus small branches pass to the fat cells, sweat 
glands, and, according to Unna, the hair papillae. From 
the upper plexus branches are given off which enter the 
papillae of the skin. There are also branches to the hair 
follicles, sebaceous glands, and the tissue of the corium 
itself. Papillae that give lodgement to a tactile corpuscle 
have no arterial twig. The veins follow the same course 
as the arteries, but, of course, in the opposite direction. 

Lymphatics. — Lymph vessels are large in the subcu- 
taneous tissue, smaller in the upper part of the corium, 
and form plexuses. "Juice spaces/' filled with lymph, 
are found abundantly in the epidermis and papillae, about 
the glands of the skin, and around the muscles of the 
skin and the connective-tissue bundles and fat lobules. 

Nerves. — The skin is provided with both medullated 
and non-medullated nerve-fibers and motor and vaso- 
motor nerves. We have learned already that non- 
medullated nerve fibers have been traced between the 
cells of the epidermis, some terminating at, if not in, 
the nuclei of the prickle cells. It may be roughly stated 
that the nerves follow pretty much the same arrange- 
ment as the bloodvessels, forming a sort of plexus beneath 
the papillae and then giving off branches to the vessels, 
the tactile corpuscles, the papillae, the hair follicles, the 
sebaceous and sweat glands, and the epidermis. 

The tactile corpuscles (corpuscles of Meissner) are 
located in the papillae. They are oval or rounded bodies, 
and their long axis runs longitudinally. Not more than 
one papilla in four is supplied with one of the corpus- 
cles, even where they are most abundant — on the end of 
the index finger. They are composed, according to Unna, 
of large, flat connective-tissue cells, which are placed 
one above the other like coins in money rolls, and take 
up between them the terminal branches of the medullated 
nerves, which on entering the bodies lose their medulla 
and finally end between the cells. The transversely 
striped appearance presented by the corpuscles is due 
to the swollen lateral edges of the cells and the band- 



CO 





Hair Follicle and Shaft. (Darier.) 



t. Shaft. 

o. Follicle mouth, of funnel shape, 
co. Neck of follicle, 
tnu. Erector pili muscle, 
s. Sebaceous gland. 
r. Radicular portion of shaft or root, 
f. Connective-tissue sheath of follicle, 
ex. External epithelial layer, 
i. Internal epithelial layer. 



i'. Internal epithelial layer, showing eleidine 
(keratohyalin) contained in the deeper 
portion, 
be. Bulb of hair shaft. The extremity is 
open and contains the papilla, 
p. Papilla. 

g. Adipose tissue of the hypodermis. 
a Arteriole in cross-section. 
n. Nerve, 
be. Coils of sweat gland. 



ANATOMY AND PHYSIOLOGY OF THE SKIN 23 

like nerve fibers that here and there appear upon the 
surface. 

The corpuscles of Krause are located in the sensory 
mucous membranes. They are rounded in shape and 
bear a close resemblance to the Pacinian corpuscles in 
structure. 

The Pacinian corpuscles are located in the subcutaneous 
tissues, and also in connection with the sensitive nerves. 
They are oval in form, visible to the naked eye, and 
consist in a colossal swelling-out of the sheath of Schwann, 
forming a thick connective-tissue capsule surrounding a 
much smaller cylindrical cavity filled with granular, 
faintly filamentous cellular substance, through the axis 
of which passes a sensitive nerve. As the latter enters 
the corpuscle it loses its medulla, and either terminates 
in the corpuscle or passes through it to enter one or more 
corpuscles. These corpuscles are most abundant in the 
fingers and toes, and the palms and soles. They are sup- 
posed to enable us to appreciate pressure or traction. 

Less well understood are the MerheVs touch cells in 
the epidermis and corium. They are ovoid in shape 
with nucleus and nucleolus. Motor and vasomotor nerves 
are also found in the skin. The former are attached to 
the smooth muscles of the skin and glands; and the 
latter to the muscles of the vessel walls, and come into 
action in blanching and flushing of the skin. 

Hair. — The hair is an epidermic structure which 
grows from a nipple-shaped projection, the hair papilla, 
situated at the bottom of a deep, slender pocket or sac- 
like depression in the skin which is called the hair follicle. 
Commencing at the papilla it is bulb-shaped. This 
part is called the bulb and fits over the papilla like a cap. 
On leaving the papilla the body of the hair is first called 
the root, and then as it becomes narrower the shaft. 
The diameter of the shaft rapidly decreases until, leaving 
the skin, it terminates in the point. A fully formed hair 
is hollow, its central cavity being called the medullary 
canal and filled with the medulla. This is composed of 



• 



24 DISEASES OF THE SKIN 

a column of cells arranged in layers, one layer being 
superimposed on another. The main substance of the 
hair is called the cortex, and consists of long, spindle- 
shaped epithelial cells flattened out into fine bands which 
run in the long axis of the hair. This part of the hair 
gives it substance and strength, and in it is placed the 
pigment that determines the color of the hair. The 
outer layer of the hair is called the cuticle. It corresponds 
to the epidermis and consists of flattened, non-nucleated, 
fully cornified cells which cover the hair like scales and 
overlap each other like shingles. 

The hair follicle is located, for the most part, in the 
corium, but in some very strong hairs it reaches down 
into the subcutaneous tissue. It is always, excepting at 
the dorsal edge of the eye-lids, placed at an angle to the 
skin, and is a permanent structure that is not removed 
when the hair is plucked. It is composed of three layers, 
which are derived from the corium as it dips down to 
form the follicle. Between the follicle and the hair is 
the root sheath, which is derived from the epidermis. It 
is composed of two layers, which are called the external 
and the internal root sheaths. The whole arrangement 
of the hair and its sheath may be graphically conceived 
by regarding the hair as a blunt needle pressed against 
the skin. The needle would form the hair, the epidermis 
would form the root sheath, and the corium would be to 
the outside of all and form the hair follicle. 

Hair is found on all parts of the body excepting the 
palms and soles, the terminal phalanges of the fingers 
and toes, the glans penis, prepuce, labia minora, and the 
vermilion border of the lips. In form it is flattened or 
rounded, straight or curled. There are three main vari- 
eties of hair: (1) long, soft hair, as of the head and 
beard; (2) short, stiff hair, as of the eye-brows and eye- 
lashes; and (3) lanugo, or soft, downy, colorless hair, that 
is scattered all over the surface of the body. 

Nails. — The nails, like the hair, are epidermic struc- 
tures. They are placed on the extensor surfaces of the 



ANATOMY AND PHYSIOLOGY OF THE SKIN 25 

terminal phalanges of the lingers and toes. Their proxi- 
mal end is called the root, under which is the matrix, 
from which they grow. On the way to their distal end 
they pass over the nail bed. This is separated from the 
matrix by a more or less convex and apparent line called 
the lunula. At their posterior and lateral margins they 
are embedded in a fold of skin that is called the nail fold. 
At their distal extremity they are separated from the 
end of the finger or toe. They are formed by the matrix, 
but in passing over the bed they receive a certain amount 
of nourishment from it, and their cells become rapidly 
cornified. They are slightly curved from side to side, 
being convex above and concave below, and are marked 
with fine lines. The flesh beneath the nail is the same 
as the skin in general, though without subcutaneous 
tissue. The nail takes the place of the corneous and 
granular layers of the skin. They are horny and trans- 
parent, and are composed of several layers. It has been 
estimated that it takes from one hundred and eight to 
one hundred and sixty-one days for a finger nail to grow 
from the lunula to the free edge, the rate of growth 
being more rapid in summer than in winter. It has been 
noted that in a case of fracture of a limb the nails of the 
fingers or toes may cease growing until the bone is well 
knit. 

Sebaceous Glands (Fig. 1). — These glands are of 
the racemose variety, and are closely related to the hairs, 
from two to six being attached to each hair, emptying 
by their ducts into the upper third of the follicle. Each 
gland is composed of a number of acini that empty by a 
common duct. They are composed of a delicate, struc- 
tureless capsule, the membrana propria, which continues 
along the duct to merge into the hair follicles. This is 
lined with large, although short, cubical or cylindrical 
epithelial cells arranged in one or two rows. These are 
continuous through the duct with the cylindrical cells of 
the outer root sheath of the hair and of the skin. The 
interior of the glands is filled with fatty secretion. 



26 DISEASES OF THE SKIN 

Around the glands passes the external layer of the hair 
follicle. These glands occur also on the vermilion border 
of the lips, the labia minora, and the glans penis and 
prepuce, though in these locations there are no hairs. 
They are not found on the palms, soles, or backs of the 
third phalanges of the fingers and toes. 

The function of the sebaceous glands is to oil the 
hair and skin, thus rendering them soft and supple, 
and giving luster to the hair. This oily secretion, or 
sebum, is produced by the cells, which, as they reach 
the central part of the acini, undergo fatty degeneration. 
It is composed of fats, fatty acids, cholesterin crystals, 
debris of cells, and water. It is forced out of the glands 
by the constant production of new sebum. The glands 
are largest in the nose, cheeks, scrotum, mons veneris, 
labia, and about the anus. It is not settled whether the 
smegma is composed of exfoliated cells alone or mixed 
with sebaceous matter. 

Sweat Glands (Fig. 1). — The sweat glands are 
simple coil glands that are located in the lower part of 
the corium and in the subcutaneous tissue. Their ducts 
ascend through the corium in a straight or wavy line 
to the interpapillary spaces, where they enter the epi- 
dermis. The cells lining the coil are simple cubical 
epithelial cells. These are seated upon muscular fibers; 
and a connective tissue, the membrana propria, comes 
outside of all. An abundant net-work of bloodvessels 
surrounds each gland and sends off branches to its 
interior. The glands are also richly supplied with nerves. 
The duct is made up of pavement epithelium upon 
the membrana propria. When the epidermis is reached 
the membrana propria is lost, and the further tract of the 
duct seems to be made by the sweat working its own 
channel up between the epidermic cells. The duct ends 
as a rounded aperture on the surface of the skin that is 
called a sweat pore. Unna teaches that the sweat pro- 
duced by the coil glands is mixed with other elements 
while passing through the epidermis, so that the secretion 



PHYSIOLOGY 27 

that appears at the sweat pores is not the same as that 
which leaves the coils. He further teaches that the 
office of the coil glands is not to produce sweat, but to 
oil the skin. This theory still needs confirmation before 
it can be accepted as proved. His arguments have con- 
siderable weight, but space will not allow of their state- 
ment here. It has long been known that there was a 
certain amount of oil in the sweat. Sweat glands are 
most numerous in the palms and soles. Their diameter 
is from 0.3 to 0.4 mm. The largest are in the axilla, 
where they have a diameter of 2 to 7 mm., and are very 
numerous. In the external meatus of the ear they 
secrete the so-called ear wax. 

Muscles. — The skin is provided with muscles, both 
of the striated and unstriated variety. The striated 
muscles are found in the face and neck. The majority 
of the muscles of the skin are involuntary muscles. In 
the scrotum they run parallel with the raphe. On the 
penis and about the nipple their direction is circular. 
The arrectores pilorum muscles are found all over the 
body, running in a more or less oblique direction from the 
bottom of several papilla? down and around a sebaceous 
gland to be attached to the bottom of a hair follicle. 
By contracting they raise the hairs to a perpendicular 
position and aid in pressing out the contents of the 
sebaceous glands.. There contraction also causes the 
appearance known as "goose flesh" when cold strikes 
the skin. 

Physiology. 

The skin is a protective, sensory, heat-regulating, and 
secretory organ. It offers protection to the deep parts 
by the pad-like structure of the subcutaneous tissue 
with its panniculus adiposus, and the highly resistant 
nature of the insensitive horny epidermis, both to physical 
and chemical agencies, and to the penetration of bacteria. 
The most vulnerable points in the skin are the pilo- 



28 DISEASES OF THE SKIN 

sebaceous openings, and these are usually plugged with 
masses of sebum. 

The end organs of touch and temperature sensation 
are located in the skin, but the delicacy of these sensations 
varies markedly in different regions. Loss of sensation 
leads frequently to the formation of traumatic lesions in 
the anesthetic area. Little is known about the existence 
of trophic nerves, although the nutrition of peripheral 
parts seem to be influenced by the central nervous 
system. 

The skin plays a very important part in the regu- 
lation of the amount of heat lost by the body through 
evaporation, radiation, and conduction. In man 77 to 
85 per cent, of the total heat loss of the body is through 
the skin. The regulation is effected through the blood 
supply and the sweat secretion. The efficiency with 
which the mechanism serves its purpose is evidenced by 
the fact that in a dry atmosphere a temperature of over 
250° F. will not produce any change in the body tem- 
perature as long as the sweat secretion remains active. 
When the body surface is exposed to cold, the sweat 
secretion is reduced to a minimum and the skin blanched 
by the contraction of the cutaneous vessels, under the 
control of the vasomotor centre. The emptying of the 
vessels is assisted by the contraction of the involuntary 
muscles of the skin, which increase the tension and the 
pressure around the vessels, and produce the condition 
known as gooseflesh (cutis anserina) . 

The sweat is 99 per cent, water, and varies in amount 
from 600 to 1300 c.c. a day, but may rise under stimu- 
lation as by heat or exercise even to 400 c.c. an hour. 
Besides its heat regulating function, it serves also to 
remove small quantities of excretives from the body 
and to keep pliable and moisten the epidermis. 

The sebum, besides lubricating the skin, prevents 
the absorption of aqueous solutions from without, and 
the evaporation of fluids from within. It is always very 



DIAGNOSIS 29 

difficult to make the skin absorb medicaments, and it 
is believed that such absorption takes place through the 
glandular orifices and mouths of the hair follicles. 



Diagnosis. 

The Lesions of the Skin. — We speak of primary 
and secondary lesions of the skin. By the first of these 
terms we mean the form assumed by the efflorescence at 
its first appearance. By the second of these terms we 
mean the subsequent changes the primary lesion under- 
goes of itself, or as the result of extraneous causes acting 
upon it. In running its course, whether influenced by 
treatment or not, almost every disease of the skin exhibits 
more than one lesion, and we can only speak of it as a 
macular, papular, or other disease from its most promi- 
nent and characteristic lesion. 

The primary lesions of the skin are the macule, the 
papule, the tubercle, the vesicle, the pustule, the bulla, 
the wheal, and the tumor. The secondary lesions of the 
skin are the crust, the scale, the excoriation, the fissure, 
the ulcer, and the cicatrix. These may be graphically 
represented, following Piffard. 1 

Primary Lesions. — A macule is a spot or stain of the 
skin which is not raised above its surface. It may be of 
any size from that of a pinpoint to that of the palm 
of the hand, or larger. Large-sized and diffused, non- 
elevated lesions are usually spoken of as patches. A 
macule is usually round, but may be of any shape. It 
may be white, red, brown, black, blue, pink, or yellow, 
according to its cause. It may be due to hyperemia, as 
in erythema simplex; to a change in the pigmentation 
of the skin, as in lentigo and chloasma, where there is 
increase of pigmentation, or in vitiligo, where there is 
decrease of pigmentation; to a hemorrhage into the skin, 

1 Cutaneous Memoranda. Wood, N. Y., 1885. 



30 



DISEASES OF THE SKIN 



as in purpura; to a development of bloodvessels in the 
skin, as in nevus vascularis and telangiectasis; to a 
parasitic growth in the skin, as in chromophytosis ; to 
a change in the consistency of the skin, as in morphea 
and xanthoma; or to the introduction of foreign matter, 
as in powder stains or tatoo marks. 



Fig. 2 



LESIONS OF THE SKIN. 



Primary. 



Macule — 



Fig. 3 

Secondary. 




Vesicle 



Pustule 



Bulla 



Wheal 



Tumor 



A 




Crust 



Scale 



Excoriation 



Fissure - 



V 



Ul( 



Cicatri 



XXX 



The macule may be evanescent or permanent; may 
remain as a macule during its existence, or may give 
place to a papule, vesicle, or pustule. It is the simplest 
of all the lesions of the skin, and is met with as a 
primary lesion in many of its diseases. 

The principal macular diseases are chloasma, chromo- 
phytosis, erythema simplex, lentigo, melasma, morphea, 
nevus simplex and spilus, purpura, scleroderma, vitiligo, 
and xanthoma. 

A papule is a circumscribed, solid elevation of the 



DIAGNOSIS 31 

skin. In size it varies from that of a pinpoint to that 
of a split pea. It may be of different colors, from white 
as in milium, to black as in melanotic sarcoma, but 
is usually some shade of red. It is soft or firm to the 
touch. In form it may be acuminated, rounded, flattened, 
or umbilicated. Its base may be round, oval, or angular. 
It may be due to inflammation, as in eczema; to hyper- 
trophy of normal structures, as in verruca; to the heap- 
ing up of epidermic cells about a hair follicle, as in 
keratosis pilaris; or to the retention of sebaceous matter 
in a follicle, as in comedo and milium. 

The papule may remain as such throughout its course, 
and finally be absorbed; or it may change into a vesicle 
or pustule; or it may soften and break down. 

Papular diseases have received the name of lichenoid 
diseases, and at one time we had a goodly number of 
lichens. Most of these have now been placed under 
other headings, as it is recognized that they are but single 
manifestations of other diseases. Papular diseases may 
be scaly and itchy. 

The principal papular diseases are lichen tropicus, 
lichen ruber acuminatus and planus, lichen scrofuloso- 
rum, lichen pilaris or keratosis pilaris, lichen urticatus or 
papular urticaria, acne, comedo, milium, prurigo, syphilis, 
and psoriasis. Like the macule, the papule is found in 
many diseases that cannot be classed as papular. 

A tubercle or nodule may be thought of as a large 
papule. Like it, it is a circumscribed solid elevation of 
the skin, usually of a reddish color. Indeed, the differ- 
ence between a papule and a tubercle is mainly arbitrary 
and for convenience. Thus we speak of a solid lesion 
up to the size of a split pea as a papule, while above that 
it is spoken of as a tubercle. Some lesions which are 
usually spoken of as tubercles, such as the tubercular 
syphilide, may not be larger than a split pea. Stelwagon 
makes the good suggestion that "a papule may be a solid 
lesion extending upward; a tubercle a solid lesion pro- 
jecting both upward and downward." Quite commonly, 



32 DISEASES OF THE SKIN 

when a lesion is larger than a cherry it is spoken of as a 
node. Auspitz 1 makes the distinction between a papule 
and tubercle on more scientific grounds, and regards a 
tubercle as a cell infiltration into the corium. A tubercle 
is not only larger than a papule, but it extends deeper 
into the skin. In form and color a tubercle corresponds 
to a papule. 

Tubercles may be absorbed and disappear and leave no 
trace; or they may break down and ulcerate and leave 
scars, as in syphilis; or they may remain unchanged for 
an indefinite period, as in molluscum. 

The principal tubercular diseases are: carbuncle, 
epithelioma, keloid, lupus vulgaris, molluscum, rhino- 
scleroma, and xanthoma. Tubercles form a very 
prominent symptom in leprosy, syphilis, and erythema 
multiforme. Of course, tubercular used in this sense 
has nothing to do with the tubercle of tuberculosis. 

A vesicle is a circumscribed elevation of the epidermis 
that contains fluid, generally serous. In size it varies 
from that of a pinpoint to that of a split pea. It may 
be unilocular, or multilocular. Its color is crystalline 
when only serum is present, more or less opaque and 
yellowish when the serum is mixed with pus, and of a 
reddish hue when blood is effused into it. It may be 
pointed, rounded, flattened, or umbilicated. Vesicles 
are in most cases due to inflammation, as in eczema. 
They may be due to simple serous effusion, as in 
erythema; or to the retention of sweat, as in sudamina. 
They have around them, in many cases, a red halo. As 
a rule, vesicles are superficial elevations of the epidermis, 
and readily rupture and pour out their contents upon the 
skin, forming a yellowish crust. They may be below the 
mucous layer of the skin. They may remain as vesicles 
and dry up, their contents being absorbed; or they may 
become changed into pustules. 

The principal vesicular diseases are: dermatitis venen- 

1 Ziemssen's Handbuch der Hautkrankheiten. 



DIAGNOSIS 33 

ata, dysidrosis, eczema, herpes, hidrocystoma, impetigo 
contagiosa, sudamina, varicella, and zoster. 

A pustule is a circumscribed elevation of the epidermis 
containing pus. In size and shape it corresponds to the 
vesicle, though the term pustule is applied to lesions up 
to the size of the finger nail. Its color is yellow and 
opaque; or brown or reddish if there is an admixture of 
blood with the pus. It either originates as a pustule or 
develops from a vesicle or papule. It may be superficial 
or deep seated. As a rule, pustules are inflammatory, and 
when they appear as a general eruption, as in syphilis, 
they indicate a strumous or broken-down condition 
Around each pustule there is very commonly a well- 
marked inflammatory areola. 

Pustules are prone to break down and discharge their 
contents upon the skin, forming a greenish crust. If 
located deep in the skin, they may leave scars. 

The principal pustular diseases are acne vulgaris, 
ecthyma, furunculosis, impetigo, and sycosis. Eczema, 
syphilis, and a few other dermatoses are often markedly 
pustular in character. Pustular diseases are often 
spoken of as impetiginous. 

A bulla, or bleb, may be considered as a large vesicle 
or pustule. It is of irregular oval shape or umbilicated. 
It may be as large as a split pea, or reach the size of a 
goose egg or larger. It rises from the skin with a slight 
areola or with none at all. It is either fully distended or 
flaccid, and does not rupture readily. It may be a bulla 
from the beginning, as in pemphigus; or it may be formed 
by the coalescence of two or more vesicles; or it may arise 
on an erythematous lesion, as in erythema multiforme. 
Its contents is usually serum, but it may change in time 
to pus. 

The only purely bullous disease is pemphigus; but 
bulla are met with in dermatitis, dermatitis herpetiformis, 
erysipelas, erythema multiforme, impetigo contagiosa, 
leprosy, and syphilis. 

A wheal is an evanescent round, oval, or elongated flat 
3 



34 DISEASES OF THE SKIN 

elevation of the skin, of a pinkish or white color, which 
is more or less firm to the touch. It is surrounded by a 
red halo. It may be as small as the head of a pin or as 
large as the palm of the hand. Wheals appear suddenly 
and disappear within a few hours. They are due to a 
spasm of the capillaries of a limited area of the skin and 
an effusion of serum into the meshes of the skin, the 
raised part being the site of the effused fluid, and the 
halo the congested vessels in the neighborhood. The 
whiteness of the wheal is due to the sudden effusion of 
the serum squeezing out the blood of the area. As the 
circulation becomes reestablished the serum is absorbed, 
the whiteness changing to pink, and then to the normal 
color of the skin. Of late it is declared that wheals are 
due to localized inflammation. The disease in which 
wheals are met with is urticaria. They can also be pro- 
duced by contact with the stinging nettle, or by sharp 
traumatism on skins predisposed to urticaria. 

A tumor is a new growth in the skin which projects 
more or less above its surface and dips down into the 
subcutaneous tissue. It may be pedunculated or sessile. 
Tumors vary greatly in size. Their color is often that of 
the surrounding skin, but it may be red, blue, or other 
color. They may be firm to the touch, or soft or elastic. 
They may become ulcerated. A tumor is rather a surgical 
than a dermatological lesion. Epithelioma, fibroma, and 
sarcoma are types of tumors. 

Secondary Lesions. — The secondary lesions of the 
skin require a much less extended description. The 
main distinction to be retained in the student's mind is 
that between a crust and a scale. This can be readily 
done if it is remembered that a crust is formed by the 
drying of some secretion or exudation upon the skin, 
while a scale is a dry, laminated mass of epidermis which 
has separated from the tissues below, the product of 
imperfect or perverted nutrition. Thus in vesicular 
eczema when the exudation dries on the skin we have a 
yellowish crust; while in squamous eczema we have thin 



DIAGNOSIS 35 

scales, the horny layer of the skin not being perfectly 
produced. Crusts are yellow when formed of dried 
serum, green when derived from pus, and black when 
there has been an admixture of blood. Scales are whitish, 
grayish, yellowish, or dirty yellow. 

Crusts are especially characteristic of ecthyma, some 
forms of eczema, favus, impetigo, seborrheal dermatitis, 
and pityriasis steatoides. 

Scales are especially abundant in dermatitis exfoliativa, 
pityriasis simplex, pityriasis rubra pilaris, psoriasis, ich- 
thyosis, and some of the lichens. 

Excoriations are familar as scratch marks. They are 
superficial denudations of the skin. They are of value 
as a sign of itching, as scratching is their chief, though 
not sole cause. They frequently are followed by pig- 
mentation if the irritation causing the scratching is long 
continued. They also occur as the natural result of some 
diseases, such as pemphigus, without the intervention of 
scratching. 

Fissures are cracks in the epidermis extending down to 
the corium. They are usually located in the folds of the 
skin, as over the joints. They may occur about the 
corners of the mouth and about the anus. They occur 
in diseases attended by infiltration and thickening of the 
skin by which its elasticity is interfered with, and are 
especially seen in eczema, psoriasis, and syphilis. They 
often bleed, and sometimes are very painful. 

Ulcers are irregularly shaped and sized losses of 
substance usually with granulating surfaces. They may 
be quite small or of large size. They may be shallow, 
deep, excavated, or scooped out. Their edges may be 
undermined, as in tuberculosis; everted, as in epithe- 
lioma; or sharp cut, "punched out," as in syphilis. 
Their secretion may be scanty or abundant. They result 
either from some previous lesion or from injury. They 
occur in carbuncle, chancre, chancroid, ecthyma, varicose 
eczema, epithelioma, furuncle, lupus vulgaris, sarcoma, 
syphilis, tuberculosis, and sometimes after zoster, der- 



36 DISEASES OF THE SKIN 

matitis, and some pustular eruptions. They always heal 
with a cicatrix, leaving a scar. 

Cicatrices, or scars, represent an effort of nature to 
heal a damage to the skin by means of connective tissue. 
They occur only when the corium has been injured. 
They may be depressed, as in smallpox; raised and 
puckered, as in lupus; smooth and white, as in syphilis. 
While ulceration usually precedes them, they occur 
independently of it, as in leprosy, scleroderma, and 
atrophoderma. 

Other Elements of Diagnosis. — We must observe 
the location, distribution, and configuration of the 
eruption, and note its color, and whether or not it itches. 
When we have done all this, and have come to a probable 
conclusion as to the disease before us, then is the proper 
time to ask the patient a few questions as to his sensa- 
tions and the duration of the attack. In a few cases of 
doubtful diagnosis the microscope will aid us. 

Location. — In the following lists those diseases are 
mentioned that occur especially in the region named, or 
with special frequency. In general eruptions, of course, 
all regions are more or less involved. 

Upon the face we meet with acne, adenoma sebaceum, 
comedo, chloasma, dermatitis venenata, erythematous 
eczema, epithelioma, erysipelas, herpes febrilis, hydrocy st- 
oma, impetigo contagiosa, lupus vulgaris and erythema- 
tosus, milium, nevus, rhinoscleroma, rosacea, sycosis, 
and xanthoma. 

An eruption confined to the middle third of the face, 
from above downward — forehead, nose, and chin — is in 
all probability rosacea. 

A pustular eruption occupying the bearded portion 
of the face, above a line drawn from the angle of the 
mouth to the angle of the jaw, is probably sycosis. 
Should it occupy the bearded portion of the face below 
that line it is probably trichophytosis barbae. 

If a scaly patch is found in front of the ear, it should 
put us on the lookout for psoriasis, which will often be 



DIAGNOSIS 37 

found elsewhere on the body. This point may be useful 
in the diagnosis of a doubtful case. If a raw, or cracked, 
or scaly place is found behind the ear, it points to eczema. 

Upon the scalp we meet with alopecia, alopecia areata, 
dermatitis seborrhoica, eczema, favus, pediculosis capitis, 
pityriasis steatoides, seborrhea, and trichophytosis. 

If we find a patch of pustular eczema upon the back of 
the head and about the nape of the neck, the case is 
probably one of pediculosis; and if we look for the nits, 
we shall find them either at the site of the eruption or 
over the parietal region. 

The chest is the favorite location for chromophytosis, 
keloid, and seborrheal dermatitis. 

Upon the back we meet with acne, carbuncle, and the 
scratch marks due to the irritation from pediculi. If we 
find long, parallel scratch marks over the shoulder-blades, 
they are very good evidence of pediculi in the clothing. 

The extensor surfaces of the forearms and wrists are 
the favorite sites of erythema multiforme, ichthyosis, 
and urticaria, while the flexor surfaces give lodgement 
to lichen planus and scabies. The posterior surface of 
the elbow is a common location for psoriasis, while on 
the soft skin of the bend of the elbow we find eczema. . 

Upon the hands occur callositas, dermatitis venenata 
and repens, erysipeloid, pernio, and pompholyx. 

Upon the legs ecthyma, elephantiasis, erythema exudati- 
vum, ichthyosis, purpura, and ulcers are apt to occur. y 

A general eruption, that is one that is scattered over 
the whole skin, is either one of the exanthematous fevers, 
dermatitis exfoliativa, eczema, erythema, ichthyosis, 
lichen planus, lichen ruber acuminatus, mycosis fungoides, 
pityriasis rubra pilaris, psoriasis, scabies, or syphilis. 

Of these, syphilis is most marked on the sides of the 
chest and abdomen, and upon the face along the margin 
of the hair. It may also be given as a general rule, to 
which there are many exceptions, that syphilis occupies 
the flexor surfaces of the extremities and the anterior 
plane of the trunk, while psoriasis is found most markedly 



38 DISEASES OF THE SKIN 

upon the extensor surfaces of the extremities and the 
posterior plane of the trunk. 

A universal eruption, that is one in which the whole 
skin is involved, is either eczema, dermatitis exfoliativa, 
erythema scarlantiniforme, ichthyosis, pityriasis rubra 
pilaris, psoriasis, or one of the exanthemata. 

Configuration. — Certain diseases assume certain config- 
uration, which, if noted, will sometimes assist in diagnosis. 
Thus we have : 

The circular outline and scalloped border of syphilis. 
The round and bald patch of trichophytosis and 
alopecia areata. 

The map-like border of psoriasis. 

The oval or egg-shaped lesions of erythema nodosum 
and the gumma of syphilis. 

The angular, umbilicated, flattened papules of lichen 
planus. 

The annular arrangement in herpes iris and pityriasis 
rosea, and in some cases of ringworm, psoriasis, syphilis, 
and dermatitis seborrhoica. 

The patches of grouped vesicles upon reddened bases 
located over the course of a cutaneous nerve in zoster. 

Color. — An eye for color is of some value in diagnosis. 
It is very difficult to convey by words a correct idea 
of the color of an eruption, but perhaps this list may 
prove helpful: 

Raw ham of syphilis. 

Brilliant red of erysipelas. 

Inflammatory red of eczema. 

Dark red of purpura. 

Bright or pinkish red of psoriasis. 

Brown of pigmentary diseases. 

Yellowish or cafe au lait of chromophytosis. 

Sulphur yellow of favus. 

Buff of xanthoma. 

Violaceous or dull red of lichen planus and lupus 

erythematosus. 
White of leukoderma. 



DIAGNOSIS 39 

History. — Having carefully noted all these objective 
symptoms, now is the time to obtain the history of the 
case, either for the purpose of scientific study of its 
etiology and natural course, or for the purpose of clearing 
up some doubt as to the diagnosis. It is so easy to obtain 
a history of syphilis that were we influenced by the 
history we would be often misled. There is no reason 
why a patient with syphilis should not have any other 
skin disease. Mo cover, most people do not pay much 
attention to the course of their diseases, and it would 
be difficult for them to give a correct account of them 
if they would. Of course, a clear history of the initial 
lesions of syphilis or its presence would clear up any 
doubt as to an erythematous rash. The history of a 
scaly disease recurring at frequent intervals upon the 
elbows and knees would go far to determine the existence 
of psoriasis. In urticaria we often have to rely upon the 
statement of the patient or attendant as to the appear- 
ance of the wheals, as their presence at some time is 
pathognomonic, and they are usually absent when we see 
the patient. In these and similar ways the history is 
useful, but it should be entirely subordinated to the 
study of the objective symptoms. 

Pruritus. — It is important to know whether a dis- 
ease itches or not. This we can discover by the pres- 
ence or absence of scratched papules or excoriations. 
The itching eruptions are dermatitis herpetiformis, 
eczema, pediculosis, prurigo, pruritus cutaneous, scabies, 
and urticaria. The symptom is also present in the 
lichens, psoriasis, dermatitis seborrhoica and tricho- 
phytosis. It is markedly absent in syphilis, although 
an occasional case of syphilis will be encountered in 
which there is itching. 

Burning. — The sensation of burning is one the exist- 
ence of which we must take upon the patient's statement. 
It is a prominent symptom in erythema. Very often a 
patient will say that his eruption itches, but if he is 
watched he will soon begin to rub his skin gently with 



40 DISEASES OF THE SKIN 

the heel of his hand. This indicates that the sensation 
is one of burning and not of itching. In itching, the nails 
are used, or else the rubbing is vigorous. 

Pain.— Another symptom for the establishment of 
which we have to rely upon the patient is that of pain. 
The vast majority of skin diseases, while they may cause 
more or less discomfort, are not painful; but sharp 
neuralgic pain is a prominent symptom in zoster, and 
occasionally in epithelioma. The presence of pain of a 
shooting character will be one point in the differential 
diagnosis between lupus and epithelioma, and in favor 
of the latter. We also meet with pain in neuroma, 
dermatalgia, and in some forms of leprosy. 

Microscope. — The principal use of the microscope in 
the hands of the general practitioner is, as far as derma- 
tological diagnosis is concerned, the determination of the 
presence or absence of fungi in hair and scales in a doubt- 
ful case of ringworm, favus, chromophytosis, or other 
parasitic disease. Happily, as between favus and ring- 
worm we seldom have need of the microscope for diag- 
nosis, their symptoms being so pronouncedly different. 
The dark stage illumination is of great use in the early 
diagnosis of syphilis in finding the spirochete . In the 
hands of the skilled pathologist and bacteriologist the 
microscope is constantly adding to our knowledge of dis- 
eases of the skin, and is of great value. 

Method of* Examination of Patients. — They should 
be always examined by daylight or by electric light. 
It is prudent to refuse to give an opinion of a case when 
seen in a poor light or by artificial light. If the patient 
is a man it is necessary to request him to strip from 
top to toe, if there is -the slightest need of seeing more 
than the ordinarily exposed parts. In the case of a woman 
such an inspection can seldom be made. The same end 
can be attained by exposing one part after another. In 
all cases we are justified in refusing to treat a case that 
we have not been given ample opportunity to examine. 

All examinations of patients should be made in a warm 



THERAPEUTIC NOTES 41 

room. The contact of cold with the usually covered skin 
is apt to give it a mottled look that obscures the diagnosis. 
It is well never to give a diagnosis of an obscure case 
that is under local or constitutional treatment until all 
treatment has been suspended for a few days and the 
disease allowed to assume its natural appearance. 

Under the name of diaskop, Unna has recommended 
the use of a small piece of thick, clear glass, marked with 
a measuring scale, for the purpose of exercising pressure 
upon the skin under examination. This does away with 
the confusing redness, brings into greater prominence 
anatomical lesions, and enables us to take accurate 
measurements of them. 

Every patient should be regarded as possibly out of 
health in some way quite apart from his skin trouble, 
and examined as to the performance of all his bodily 
functions quite as carefully as if he had come to us only 
for the treatment of some internal disorder. 

Therapeutic Notes. 

Many new preparations are constantly being introduced 
by manufacturing chemists. Anyone interested in them 
can readily procure information from his druggist. Most 
of those which have approved themselves as of value 
will be found in the sections on treatment that follow. 
It is our purpose here to describe concisely the methods 
of using those physical agents that at present are em- 
ployed in the treatment of dermatoses. 

Aciinotherapy. — Direct sunlight has long been known 
as a bactericide. In most countries the hours of sunlight 
are short and uncertain. This led Finsen, of Copen- 
hagen, to introduce a method of light therapy by means 
of electric light. Further investigations have shown that 
the blue, violet, and ultraviolet rays of the spectrum are 
bactericidal; and that light can be made to penetrate 
the skin and cause reactive structural changes of a 
destructive nature. Since Finsen introduced his lamp, 



42 DISEASES OF THE SKIN 

a number of lamps have been put on the market, only a 
few of which can be mentioned here. 

Finsen-light therapy is the use of an electric arc light 
of 60 to 80 amperes and about 70 volts concentrated 
by means of telescopic tubes through lenses of rock 
crystals upon the part to be treated. The lenses are 
kept cool by a stream of cold water. They permit 
the ultraviolet rays to pass through them. To render 
this light effective the blood must be pressed out of the 
tissues. This is done by an attendant, who presses upon 
the skin pieces of quartz in a special holder. Painting 
the skin with a 5 per cent, solution of eosin increases the 
penetration of the light. The exposures have to be 
made for from half an hour to two hours daily until 
reaction sets in, and repeated when the reaction caused 
by the treatment subsides. The amount of reaction 
will vary from an erythema to the production of bullae 
depending upon the degree of exposure. The process is 
tedious and expensive, months and years being required 
for the cure of some cases. Lupus erythematosus, 
lupus vulgatis, and the tubercular diseases are those 
in which this treatment has given the most brilliant 
results. None of the substitutes for the Finsen apparatus 
are as effective as it is. Next in efficiency is the Finsen- 
Reyn lamp. 

Iron electrode lamps are also used either with or without 
a quartz lens, such as the Piffard lamp. The latter is 
more active without the lens. A current of 12 to 25 
amperes is to be usedj the lamp held from 2 to 5 inches 
from the area to be treated, and the exposure made from 
two to ten minutes daily, or every second or third day. 
After a number of exposures, the skin may become tanned 
as from sunburn. This lamp is especially useful in alopecia 
areata. It is said to be rich in ultraviolet rays, and is 
superficial in its action. 

Mercury vapor lamps are glass vacuum tubes contain- 
ing a certain amount of mercury, which is vaporized by 
passing through it a current of electricity. They are 



THERAPEUTIC NOTES 43 

very rich in blue, violet, and ultraviolet rays. The 
Heraeus, and the Sehott lamps are types of this form of 
lamp. The latter is called the "uviol" lamp. The most 
powerful of these lamps is the Kromayer (Fig. 4). It 
is made of quartz inside of a metal jacket, through which 
a stream of water circulates to keep it cool. In the front 
of it are two columns of mercury. When the electric 
current is turned on an arc of mercurial vapor is 
developed. It is furnished with variously sized appli- 
cators, some of blue color. The operator must wear 
simple glass spectacles to protect his eyes. For surface 
action it is held at a distance of 2\ inches or more from 
the point of application and accurately focussed on it. 
Three minutes' exposures produce bulla?. Armed with a 
Sehott blue ultraviolet glass applicator it ma}' be pressed 
directly upon the skin for twenty to thirty minutes where 
deep action is called for. Exposures are to be repeated 
when the reaction subsides. It is a powerful bactericide. 
It has been found useful in acne, alopecia areata, derma- 
titis herpetiformis, chronic eczema, furunculosis, lupus ery- 
thematosus, nevus vasculosus, prurigo, psoriasis, rosacea, 
and sycosis. 

Radiotherapy 1 is the therapeutic application of the 
a>ray to the human tissues. In recent years great ad- 
vances have been made in technique — in the efficiency 
of exciting apparatus, in a>ray tubes and in instruments 
for accurately measuring the dose. Static machines 
have been discarded. Induction coils of the Ruhmkorff 
type are extensively employed still, but the apparatus 
receiving the most favor at the present moment is the 
interrupterless transformer; x-ray tubes can now be 
obtained that can withstand heavy currents for suffi- 
ciently long periods of time. While the expensive water- 
and air-cooled tubes possess obvious advantages, they 
are not necessary. It may be said, too, that American 
tubes and exciting apparatus are as good if not better 

1 This section is contributed by Dr. George M. MacKee, who has done 
very much to advance our knowledge of the exact use of rc-rays. 



Fig. 4 




j^dhs* 



otH 



The Kromayer lamp, a, lamp connecting plug; b, current direction 
indicator; c, plug connection; d, tube connection; e, winged nut for fixing 
lamp in fork g; f, Kromayer quartz lamp; g, fork lamp holder (may be 
fixed in any position) ; h, j, inlet and outlet for cooling water; k, switch; 
/, rheostat lever; m, line connection-; n, rheostat. 



THERAPEUTIC NOTES 45 

than those of foreign make. The dangers of the a;-ray 
are so well understood now, that injury to the operator 
or patient is an uncommon occurrence. The operator 
protects himself by remaining in a lead-lined booth 
during the entire exposure. This booth is provided with 
a lead-glass window for observation, and contains the 
switches, rheostats, and measuring instruments. The 
patient is protected by the tube being placed in a 
lead-glass receptacle, the under surface of which con- 
tains an adjustable diaphragm composed of lead. In 
this manner only the diseased area is exposed to the 
ray. 

The estimation of the dose is based upon the deter- 
mination of the quality and quantity of ray employed. 
By quality is meant the "hardness" or penetrating 
ability. A "soft" or low-vacuum tube emits rays of 
slight penetration, rays that are absorbed to a large 
extent by the epidermia. A "hard" or high- vacuum 
tube, on the other hand, produces rays of great penetration 
and which are similar to the gamma rays of radium. 
Obviously, there must be many gradations between these 
extremes — and, indeed, such is the case. And, further- 
more, the vacuum of a tube when in action can be 
regulated so that a maximum of rays of any desired 
penetration may be obtained. Because of the desir- 
ability of penetrating the thickened horny layer, the 
oedema and congestion of the rete and papillary bodies, 
existing in many dermatoses amenable to .T-ray therapy, 
and having most of the effect exerted in the dermis, 
a "hard" ray is indicated in the treatment of even ap- 
parently very superficial conditions. Also, the latitude 
of safety in the case of the "hard" ray is many times 
greater than when a "soft" ray is employed. 

The quality is estimated by the combined use of the 
Benoist radiochromometer, the milliamperemeter and the 
Heinz-Bauer qualimeter. 

The quantity is best determined by the aid of the 
Holzknecht radiometer. This instrument consists of a 



46 DISEASES OF THE SKIN 

standard color scale, which is divided into units, and 
with it are supplied pastilles or tablets of platino-cyanide 
of barium. This is a chemical combination of a green 
color which becomes brown upon exposure to the ar-ray. 
By comparing the exposed pastille with the graded 
color scale any number of units of a given quality may 
be applied. 

This is known as the direct method of measurement 
in contradistiction to the indirect method, where the 
dose is estimated by the amount of current used, the 
distance of the tube from the patient and the length 
of time occupied by the exposure. The latter method 
is falling rapidly into disuse, because it is not nearly 
as accurate as is the direct method. 

The cc-ray is now employed in a much more intensive 
manner than formerly. Today, very few operators 
give more than 6 or 8 exposures to cure an epithelioma, 
and some of them do not administer more than one or 
two treatments. Indeed, the same may be said of most 
of the cutaneous affections that are amenable to radio- 
therapy. Heretofore, however, from 50 to 200 exposures 
were required to obtain the same result. In other words, 
the maximum amount of benefit is now obtained with the 
minimum amount of ray — a fact of very great importance 
when one remembers that an excess of avray is decidedly 
injurious. 

It is impossible, in a book of this kind, to give details 
regarding the apparatus, the various instruments, and the 
methods of employing them, nor can details regarding 
dosage, etc., be entered into. A short bibliography 1 is 

1 Schultz, The X-ray in Skin Diseases, Rebman Co., New York. 
Belot, Radiotherapy in Skin Diseases, Rebman Co., New York. Stein, 
The Holzknecht Radiometer, Med. Rec, May 20, 1911. MacLeod, 
The X-ray Treatment of Ringworm of the Scalp, Lancet, May 15, 1909. 
Hampson, The Epilation Dose, Arch. Rontgen Ray, August, 1911. 
MacKee and Remer, A Technique for Measuring the Quality and 
Quantity of the X-ray, with a Discussion Regarding the value of the 
Pastilles of Platino-cyanide of Barium, Am. Jour. Rontg., December, 
1913. MacKee and Remer, The Massive-dose X-ray Treatment 
of Cutaneous Epithelioma, Med. Jour., New York, March 29, 1913. 
MacKee and Remer, The Single-dose X-ray Method, Jour. Cutan. 
Dis., 1912, xxx, p. 528. 



THERAPEUTIC NOTES 47 

appended herewith for the guidance of those who desire 
to be better informed. Indications for a>ray treatment 
will be found throughout the book under the descriptions 
of various diseases. 

Radium exerts an action similar to the Rontgen rays. 
The material is still too rare and expensive for it to come 
into common use. The bromide salt is the one used 
with a radioactivity of 7000 to 200,000 units or more. 
It is enclosed in aluminum- or mica-covered capsules 
or glass tubes and retained in contact with the skin 
from twenty minutes to an hour or more. It is used 
for the destruction of new growths. It is probably 
inferior to the a>ray, but convenient to use in the 
cavities of the body and for insertion into tumors. 

Fig. 5 




Piffard's roller electrode. 

High-frequency Currents. — These are electric currents 
of high potential and great frequency generated by a 
coil acting usually through an Oudin resonator. The 
current is applied by means of a handle into which 
fits a vacuum glass tube of any desired shape; or 
by means of a point of carbon or platinum fitting into 
the same handle; or by the Piffard roller electrode. 
When the electrode is approached to the skin a violet 
light fills the tube, and a shower of sparks fall upon 
the skin, giving rise to a tingling sensation. When the 
tube is in contact with the skin, tingling is not felt, and 
there are no sparks; but the tube feels warm. These 
currents are used for stimulation, as in acne, chronic 



10 



48 DISEASES OF THE SKIN 

eczema, and alopecia; to relieve pruritus; and to destroy 
warts and new growths. Fulguration, or high-frequency 
cauterization, is effected by means of the carbon or 
platinum point. By it warts and vascular nevi and 
other small growths may be destroyed. 

Congelation. — There are four agents used for freezing 
the skin for therapeutic purposes: 

1 . Chloride of ethyl. — This occurs in the form of a glass 
bulb containing the liquid, which runs out into a capillary 
tube. When the bulb is held in the hand its warmth 
drives a fine stream of fluid out of the end of the tube, 
which soon congeals the part. 

2. Rhigolene. — This may be sprayed on the skin with 
an ordinary hand atomizer. It produces a temperature 
of 51° below zero Fahr. Though these two have been 
recommended in the treatment of lupus erythematosus, 
they are used practically only for the production of local 
anesthesia, for the opening of abscesses, and for taking 
sections of the skin for biopsies. 

3. Carbon Dioxide. — This comes in iron cylinders 
furnished with a stop-cock, and is familiar as a part of 
the fitting of a soda fountain. Boyer 1 suggests the use 
of Presto-fire tubes for making C0 2 snow. A tube 
contains sufficient to use once. They are convenient 
to carry. In order to use the gas, the cylinder should 
be slightly tipped up, and a piece of chamois skin in 
several thicknesses wrapped about the vent of the 
cylinder, so as to form a little bag. The stop-cock is 
then opened carefully, and the gas allowed to escape, 
which it does with the sound of escaping steam. In a 
few moments enough snow has formed in the bag, by 
condensation, and then the stop-cock should be closed. 
The snow is moulded with the fingers into a mass which 
may be whittled to any desired size or shape. Special 
apparatuses are on the market for collecting this snow. 
We use one invented by S. Dana Hubbard. It is made 

1 Jour. Amer. Med. Assoc, 1912, vol. lviii, p. 1939. 



THERAPEUTIC NOTES 49 

of a perforated brass plate turned up into a cylinder. 
This is split down the back and the two sections united 
by hinges. It is covered with chamois leather, and fitted 
with a nut that screws on to the vent of the C0 2 cylinder. 
If a very small lesion is to be treated it is convenient 
to force a little of the snow into an ear speculum. Its 
temperature is about 90° below zero, Fahr. The snow 
is simply pressed against the skin, and the depth to 
which the freezing is carried depends upon the length 
of the time it is in contact with the skin and the 
degree of pressure which is used. After ten seconds' 
pressure the skin is white and hard, a wheal forms in 
ten minutes, and in six to ten hours there is a circum- 
scribed area of inflammation with vesicles. A thin crust 
subsequently forms that falls without a scar. After 
twenty seconds a bulla will form in six to eight hours, 
followed by a crust that falls in ten days. After thirty 
seconds a dry eschar forms that falls in about three weeks 
without ulceration, and leaving a superficial, smooth, 
white scar. If deep destruction is desired, the freezing 
is to be repeated. 

4. Liquid Air. — This is atmospheric air condensed by 
special machinery under great pressure and in the pres- 
ence of cold. Its temperature is about 312° below 
zero, Fahr. It looks like water. It is dispensed in 
specially constructed glass flasks, with double sides. 
between which is a vacuum. The expansion of the air 
is so great that the flask cannot be corked tightly, but 
with a loose-fitting cotton plug. The most convenient 
way to use the air is by means of a swab made by winding 
absorbent cotton on a stick. This is dipped into the 
liquid and pressed against the skin. Its action is simi- 
lar to that of carbon dioxide, but as it is three times 
colder its effects are attained in much less time. The 
actual freezing is not very painful, but the thawing out 
is. The pain may be somewhat mitigated by the appli- 
cation of cold water. 

Congelation is a good means for the destruction of all 
4 



50 DISEASES OF THE SKIN 

sorts of nevi. In deep port- wine marks it is of doubtful 
efficacy. It is one of the best methods for the treatment 
of lupus erythematosus. It may also be used for the 
destruction of senile and other warts, and small super- 
ficial epitheliomas. 

Massage is of use in stimulating hair growth in alopecia 
areata, and in other forms of alopecia where there is no 
disease of the scalp. Also in scleroderma, elephantiasis, 
and circulatory diseases. It sometimes does good in acne, 
more often harm. It may tone up flabby skin, as in 
wrinkles, but does no permanent good. 

Caiaphoresis is the passing of medicaments into the 
skin by moistening the positive electrode with the drug 
and letting the current run for five or ten minutes, using 
a strength of 10 ma. Cocain, iodin, and salts of copper 
have been so used when indicated. 

Bacteriotherapy or Vaccine Therapy} — Phagocytosis is 
probably the most active defensive process the animal 
body has against the invasion of microorganisms and 
the maintenance of active immunity. It was through 
the investigation of the power of the leukocytes to 
ingest bacteria in health as compared with disease that 
Wright and Douglas discovered that this power was 
dependent upon certain substances in the blood stream, 
which they called " opsonins." The opsonin seemed to 
prepare the bacteria in such a way that the leukocytes 
were enabled to ingest them. They found that the pre- 
paring substances or opsonins could be markedly increased 
by injecting into the animal body killed cultures of dead 
specific bacteria. By comparing the phagocytic power 
of an infected individual's serum with that of normal 
serum for the same bacteria, an index was established 
by Wright and his pupils, called the opsonic index, 
which, on account of its proved unreliability and imprac- 
ticability for general use, has been largely discontinued, 
except for accurate research. 

1 Contributed by Dr. M. F. Engman, of St. Louis. 



THERAPEUTIC NOTES 51 

The nature of the bodies called opsonins is not known, 
but they are probably derived from the tissue cells of the 
general economy stimulated to the formation of such an 
antibody by the bacterial products absorbed into the 
general circulation from the foci of infection. It is 
therefore necessary for an antigen or bacterial products 
to enter the general circulation in sufficient quantity 
to stimulate and not overwhelm the cells of the tissues. 
According to Sir A. E. Wright, primary infection occurs 
on account of the lessened quantity of opsonins in the 
blood; the opsonic content does not drop because of 
the infection. 

As opsonins are formed by the tissue cells only upon 
stimulation by the bacterial products of the invading 
microorganisms, it is obvious unless these products 
enter the general circulation such stimulation cannot 
occur and the distant tissue cells cannot send into the 
general blood stream the necessary assistance to the 
infected force — namely, the chemical antibody to prepare 
the bacteria for ingestion of the opsonin. 

If the infected foci be walled off by proliferating con- 
nective tissue, fibrin, broken-down tissue, and other 
products of inflammation, or, if the foci be in a follicle 
in which the walls are dense and resistant, or in any 
position where there is not free interchange of secretions 
or lymph, very little of the bacterial products escape into 
the blood stream and the foci do not heal and the con- 
ditions become chronic. In such instances the bacteria 
are protected from the antibodies formed in the system 
and the formation is therefore at a minimum. Wright 
and his pupils elaborated, by the investigation of these 
chronic, walled-off infections in the skin, a form of therapy 
which has proved of great value when properly used. 
This form of therapy is based upon the fact that by the 
injection of an emulsion of dead bacteria, specific for 
the infection, into the tissues of an infected individual, 
under the above conditions, the antibody formation is 
thereby increased, and if at the proper time the lymph 



52 DISEASES OF THE SKIN 

be guided with its freshly formed antibodies to the in- 
fected foci, clinical improvement results. Unfortunately 
immediately after the injection and for several hours or 
days, a depression of antibody formation is experienced 
and the opsonic content of the blood is lowered, consti- 
tuting the "negative phase" of Wright, to be followed by 
a gradual rise above the normal or the " positive phase." 
The negative phase is greatly prolonged by a large dose 
of bacteria, which is an element in the failure of the 
method. The dose of bacteria is approximate, but is 
definitely controlled within certain limits. 

The cultures for treatment should be derived from the 
foci of the infected individual when possible, but in 
the large general run of cases, stock vaccines will prove 
serviceable; but in every instance the offending organism 
should be accurately determined. The principal points 
to be observed in using this form of therapy are: 

1. To determine the offending organism when a 
"stock" vaccine can be used, and in event of failure of 
the stock suspension, an autogenous vaccine should be 
made. The latter, however, is always preferable. 

2. The initial dose should be small and the size of each 
dose very gradually increased and interspaced according 
to clinical results. 

3. The fresh immunizing serum should be gently 
guided to the various foci by means of hot applications. 
Bier's hyperemia, the various ultraviolet-ray lamps, 
sunburn, chemical agents, and such other means as will 
cause hyperemia or "reactionary hyperemia." 

4. No manipulation or hyperemia should be encouraged 
during a "negative phase," therefore at least forty-eight 
hours should elapse between an injection and local 
treatment. 

Classification. 

In the present state of our knowledge it is impossible 
to make a satisfactory classification of skin diseases. 
Many attempts have been made to do this, and are still 



CLASSIFICATION AND NOMENCLATURE 



53 



being made. Hebra's classification modified is found in 
a great many text-books. The arrangement of this book 
does away with classification. The one here given 
follows that given by Crocker, and has proved itself, 
after a number of years of use, a practical one. 



CLASSIFICATION AND NOMENCLATURE. 



Class I. HYPEREMIA. 

II. EXUDATIONES. 

HEMORRHAGES. 
IV. HYPERTROPHIC. 
V. ANOMALIES OF PIGMENTATION. 
ATROPHIC 
NEUROSES. 
NEOPLASMATA. 
MORBI APPENDICUM. 



III. 



VI 

VII 

VIII 

IX 



X. PARASITE 

Class I. HYPEREMEE— CONGESTIONS. 

Most prominent primary lesion. 
Erythema. 



Erythema simplex. 
pernio, 
intertrigo, 
scarlatiniforme. 
fug ax. 
roseola. 



Class II. EXUDATIONES— INFLAMMATIONS. 



Erythema exudativum multiforme. 

Peliosis rheumatica. 

Erythema nodosum. 

Erythema nodosum elevatum diu- 

tinum. 
Pellagra. 
Acrodynia. 
Urticaria. 

pigmentosa. 
Eczema. 
Dermatitis repens. 

Impetigo contagiosa. 
Folliculitis. 
Pompholyx. 
Herpes. 

progenitalis. 
Zoster. 
Pemphigus. 

neonatorum. 
Epidermolysis bullosa. 
Equinia. 

Hydroa seu Dermatitis herpeti- 
formis. 



Most prominent primary lesion. 
Erythema and papules. 

Erythema in soft swellings. 



Erythema. 

Wheals. 

Persistent wheals. 

Multiform lesions. 

Epidermic denudation and fluid 

exudation. 
Vesicles and pustules. 
Hair-follicle pustules. 
Bullae and vesicles. 
Grouped vesicles. 



Bulla?. 



Multiple lesions. 

Grouped multiform lesions. 



54 



DISEASES OF THE SKIN 



Impetigo herpetiformis. 
Dermatitis. 

epidemica. 
Psoriasis. 

Pityriasis rubra sen Dermatitis ex- 
foliativa. 
Pityriasis rosea. 

Lichen scrofulosorum. 
" pilaris. 
" planus. 

ruber. 
" variegatus. 

Pityriasis rubra pilaris. 

Prurigo. 

Furunculus. 

Carbunculus. 

Abscess. 

Pustula maligna. 

Ulcus. 

Erysipelas. 

Conglomerative pustular folliculitis. 

Dermatitis gangrenosa. 



Most prominent primary lesion. 
Qrouped pustules. 
Multiform lesions. 
Erythema and papules. 
Scaly crusts on red base. 
Diffuse redness with large scales. 

Oval, scaly, red patches, with yel- 
lowish centre. 
Papules, grouped. 
" follicular. 

flat, angular. 

acuminate, scaly. 

flat, and reticulated scaly 

spots, 
acuminate, scaly. 
" lenticular. 
Phlegmonous. 



Loss of substance. 

Erythema with brawny swelling. 

Patches of aggregated pustules. 

Gangrene. 



Purpura. 
Scorbutus. 



Class III. HEMORRHAGIC— HEMORRHAGES. 
Blood extravasation. 



Class IV. HYPERTROPHIC— HYPERTROPHIES. 

Parts affected. 
Ichthyosis. Epidermis and papillae. 

Keratosis pilaris. Papules about hair follicles. 

Acanthosis nigricans. Epidermis and papillae. 

Verruca. 
Clavus. 

Cornu cutaneum. 
Callositas, 
Tylosis. 
Porokeratosis. 
Angiokeratoma. 
Keratosis follicularis. 

" pilaris. 

Scleroderma. 
Morphea. 

Sclerema neonatorum. 
(Edema " 

Elephantiasis. 
Acromegaly. 



Epidermis. 

Sweat-orifice keratosis. 
Folicles. 

Hair follicles. 
Corium. 



Whole skin. 



Class V. ANOMALIES OF PIGMENTATION. 



Chloasma. 

Lentigo. 

Albinism. 

Leukoderma. 

Melanoderma. 



Pigment. 



CLASSIFICATION AND NOMENCLATURE 

Class VI. ATROPHIA— ATROPHIES. 
Parts affected. 
Atrophia cutis propria. Corium. 

Atrophoderma senilis. 
Atrophoderma striatum et macu- 

latum. 
Atrophoderma pigmentosum. 
Ainhum. 

Class VII. NEUROSES— SENSORY DISEASES. 

Hyperesthesia. 
Dermatalgia. 
Pruritus. 
Anesthesia. 
Ulcus perforans. 
Morvan's disease. 

Class VIII. NEOPLASMATA— NEW GROWTHS. 



Molluscum 

Colloid degeneration 

Xanthoma 

Lupus vulgaris 

erythematosus 
Scrofuloderma 
Tuberculosis 

verrucosa cutis 
Erythema induratum 
Syphiloderma 
Lepra 

Rhinoscleroma 
Leukoplakia 
Keloid 
Fibroma 
Acrochordon 
Myoma 
Neuroma 
Nevus pigmentosus 

vasculosus 
Telangiectasis 
Angioma serpiginosum 
Angiokeratoma 
Rosacea 
Lymphangioma 
Dermatolysis 
Carcinoma 
Paget's disease 
Epithelioma 
Sarcoma 
Sarcoid 
Leukemia and pseudoleukemia 

cutis 
Mycosis fungoi'des 
Yaws 

Verruga peruana 
Furunculus orientalis 
Phagedena 
Acanthoma 



Degeneration. 



Infiltrating. 



Benign. 



f Malignant. 



56 



DISEASES OF THE SKIN 



Class IX. MORBI APPENDICUM— DISEASES OF THE 
APPENDAGES. 



A. Sweat Glands. 
Hyperidrosis. 
Bromidrosis 
Chromidrosis 
Hsematidrosis 
Uridrosis 

Anidrosis. 

Miliaria crystallina (sudamina) . 

papulosa. 
Hydrocystoma. 

B. Sebaceous Glands. 
Seborrhcea. 

Seborrheic dermatitis. 
Milium. 
Comedones. 
Acne vulgaris. 

rosacea. 

varioliformis. 
" agminata aud folliclis. 

Sebaceous cyst. 
Adenoma sebaceum. 

Asteatosis. 

C. Hair. 

Hypertrichosis. 

Atrophia. 

Alopecia. 

" areata. 

Concretions. 
Trichorrhexis nodosa. 
Canities. 
Sycosis. 

Folliculitis decalvans. 
Dermatitis papillaris capillitii. 
Nevus pilosus. 

Plica polonica. 

Trichiasis. 

Distichiasis. 

D. Nails. 
Pterygium. 
Onychia. 
Paronychia. 
Atrophia. 
Onychogryphosis. 
Onychomycosis. 
Leukopathia unguium. 



Most prominent primary lesion. 
Excessive secretion. 

> Altered quality. 

Deficient secretion. 
Vesicles. 
Inflammation. 
Vesicles. 



Excessive secretion. 

Multiple inflammatory lesions. 

Retained secretion. 

Inflammation. 

Redness and pustules. 

Inflammation. 

Aggregated and disseminated 

pustules. 
Retained secretion. 
Papules. 
Deficient secretion. 



Excessive growth. 
Defective growth. 
Baldness. 

" in patches. 
Growths on the hair shaft. 
Nodes on hair shaft. 
Loss of pigment. 
Inflammation. 
Alopecia with inflammation. 
Inflammation. 

Excessive growth with pigmenta- 
tion. 
Felting. 
Misplacement of cilia. 



Overlapping of nail fold. 
Inflammation. 

Defective growth. 
Overgrowth. 
Fungus growth in nail. 
White spots in nails. 



CLASSIFICATION AND NOMENCLATURE 



57 



Class X. PARASITI— PARASITES. 



A. Vegetable. 
Favus. 

Trichophytosis. 
Tinea imbricata. 

A. Vegetable. 
Chromophytosis (tinea versicolor) . 
Erythrasma. 

Mycetoma. 
Actinomycosis. 
Pinta. 
Blastomycosis. 

B. Animal. 
Scabies. 

Demodex folliculorum. 

Leptus autumnalis. 

Pulex penetrans. 

Estrus. 

Larva migrans. 

Pediculosis. 

Cysticercus cellulosa cutis. 

Dracontiasis. 



Parasite- 



-Achorion. 
Trichophyton. 



Parasite — Microsporon. 

Parasite — Microsporon minutissi- 

mum. 
Tumors. 

Discolored macules. 
Tumors. 



Parasite — At 



Parasite — Pediculus. 
" — Tenia solium. 
" — Filaria medinensis. 



PART II. 

THE DISEASES OF THE SKIN AND THEIR 
TREATMENT. 

Abscess. 

Symptoms. — Abscesses are very frequently met with 
as complications of diseases of the skin, such as acne, 
eczema, scabies, pediculosis, and other acute dermatides. 
As thus met with they are usually of small size, though 
at times, as upon the scalp of a strumous child, they may 
attain considerable dimensions. They form rounded 
swellings that are at first tense but soon become soft 
and fluctuating. When incised, more or less thick pus 
escapes. Their most frequent locations are: upon the 
scalp with eczema; upon the face and back with acne; 
about the neck arising from broken-down glands; and 
upon the extremities with scabies and pediculosis. Apart 
from a slight amount of discomfort, they do not give 
rise to subjective symptoms, as a rule, and are, indeed, 
trivial affections. Of course, this does not apply to 
abscesses as seen by the surgeon. They may open of 
themselves and discharge their contents upon the skin. 
More commonly they are very sluggish in their course, 
and must be evacuated by some surgical procedure. 
Cutaneous abscesses are most commonly due to micro- 
organisms. 

Diagnosis. — An abscess differs from a furuncle by not 
being raised into a conical mass ; not having a central core, 
and by being less firm to the touch. It differs from a 
carbuncle by an entire absence of marked constitutional 
disturbance, brawny infiltration, intense inflammation, and 



60 DISEASES OF THE SKIN 

cribriform mode of opening. Kerion often resembles an 
abscess, but differs from it in its uneven surface and its 
firmness to the touch. Syphilitic gummas are sometimes 
mistaken for abscesses and opened. They may be 
recognized by their dark red color, the absence of pain 
and discomfort, and the history of their growth. They 
grow slowly, beginning below the skin. There is generally 
more than one present, and then they are grouped. The 
aspiration of the tumor will decide the question. From 
an abscess we obtain pus; from a gumma a little bloody 
fluid. 

Treatment. — The management of the small cutaneous 
abscesses that we meet with as dermatologists is simple. 
The cavity is to be opened, the pus allowed to escape, 
and the part dressed with carbolized vaselin if small, or 
antiseptically if larger. It is sometimes necessary to 
swab out the cavity with a solution of carbolic acid, 
either 95 per cent., if the abscess is small, or of two 
drachms to the ounce, if large, to destroy the abscess 
wall and prevent the re-formation of the abscess. 

Acantholysis. — A disease characterized by loosening or 
separation of the mucous layer of the epidermis. (See 
Epidermolysis.) 

Acanthosis Nigricans. — Under this name cases have 
been reported by Politzer, Janovsky, Crocker, and a 
few others. It occurs at any time of life, but most often 
between the thirtieth and fortieth year. The first symp- 
tom may be pigmentation of the face and neck; or an 
eruption of warts on the backs of the hands or thighs; 
or itching on the inside of the thighs or in the mouth. 
Later there is a dirty brown to ' bluish-gray or black 
discoloration of the skin and mucous membranes, with 
more or less papillary outgrowths and seborrheal warts. 
On the places that are most discolored the papillary out- 
growths are most marked. The skin is thickened to a 
greater or lesser degree, and is not scaly. The eruption is 
more or less general, but the regions most often affected 



ACARO-DERMATITIS URTICARIODES 61 

are the face, neck, mucous membranes of the mouth 
(especially the tongue), the backs of the hands (especially 
the fingers), the axillse, groins, genito-anal regions, and 
abdomen. Keratoses of the palms and soles are often 
found. Women are more often affected than men. 
Most cases occur after the forty-sixth year. It may 
occur as early as the second year. Late in the disease 
the hair and nails are lost. The cause of the disease is 
unknown. Rille 1 regards it as a form of keratosis. Darier, 
J. Burmeister, 2 and others say that it is often due to 
cancer affecting the abdominal sympathetic. The prog- 
nosis is bad, death resulting in from eight months to 
two years. In some cases the duration is much longer. 
In children and in young adults the prognosis is better, 
as in them it may remain stationary for an indefinite 
time. A cancerous cachexia is often developed and 
cancerous degeneration of some abdominal organ recog- 
nized. Treatment thus far has been unavailing. 

Acaro-dermatitis Urticariodes, or Grain Itch. — Schamberg 3 
and others have reported cases of this disease occurring 
epidemically. The eruption consists of wheals, many of 
which have at their summit a central pinpoint-sized 
vesicle, at first clear, later becoming cloudy. There may 
be barely elevated erythemato or papulo-urticarial lesions. 
The lesions vary in size from a lentil to a finger nail, and 
are either round, oval, or irregular in shape. They are 
rosy in color, rarely pinkish white. There are many 
excoriations. The eruption is usually profuse on the 
trunk, while the hands, feet, and face are often spared. 
Itching is pronounced, especially at night. At first 
there may be chilliness, a temperature of 100° to 102° F., 
nausea and vomiting, which may last several days, 
though many patients are not at all ill. The duration 
of the disease is from seven to ten days, the eruption 
beginning to fade in from twelve to thirty-six hours. 

1 Wien. med. Wochenschr., 1897, xlvii, 1019. 

2 Arch. f. Dermat. u. Syph., 1899, xlvii, 343. 

3 Jour. Cutan. Dis., 1910, xxviii, 67. 



62 DISEASES OF THE SKIN 

The histopathology is the same as that of urticaria. 
A moderate leukocytosis and eosinophilia are present in 
most cases, and albumin is found in the urine. 

Etiology. — The disease is due to irritation of the skin 
by the pediculoides ventricosus, a mite that invests 
straw. All the patients give a history of having slept 
on fresh straw mattresses or fresh straw. 

Diagnosis. — It is distinguished from urticaria by its 
longer duration, central vesiculation, more marked 
constitutional disturbances, and its epidemics in groups. 
Varicella runs a shorter course, its vesicles are larger 
and are not seated on wheals, and it lacks the intense 
itching. The lesions of scabies are scratched papules which 
are found in certain definite locations, more especially 
the extremities, and the disease has no constitutional 
disturbance. 

Treatment. — The clothing and mattress should be 
disinfected. The patient is to be given a warm bath, 
and his skin anointed with such an ointment as 
/3-naphtol, gr. xxx (2), sulphur precipitat, gr. xl (2.66), 
adepis benzoat, §j (32). 

Acne. — Synonyms: (Ger.) Finnen; (Fr.) Acne, Bouton; 
Stone-pock, Pimple. 

Acne is an inflammatory disease of the sebaceous 
glands and the hair follicles, characterized by an eruption 
of papules, pustules, or nodules upon the face, neck, 
shoulders, or chest, which usually begins at puberty and 
tends to run a chronic course. 

There are two varieties of acne, namely, acne vulgaris 
and acne indurata. 

Acne Vulgaris, or Simplex, is either papular or pustular 
in character, though usually it is a combination of the 
two, together with more or less comedones and a certain 
amount of seborrhea. 

Symptoms.— If only papules exist (A. papulosa), the 
face, shoulders, or chest will be found to be dotted more 
or less profusely with pinhead-sized acuminated eleva- 



ACNE VULGARIS 



63 



tions of the skin, of a pinkish to red color, and with a 
central opening at the summit. Very often the central 
openings will be filled with blackish specks. The lesions 
are then spoken of as A. punctata. There are many 
comedones present. It is rare that acne exists only in 
the papular form. More usually it will be found that 
here and there the papules are surmounted by a pustule, 
or a pustule has taken the place of a papule. We now 
have A. pustulosa. The central black point is wanting. 



Fig. 6 










€* 







Acne vulgaris. By courtesy of Dr. S. I. Rainforth. 

In strumous subjects the pustular element preponderates 
over the papular, and the face may be greatly disfigured 
by the large number of lesions upon it. The pustules are 
from pinhead to small-pea size, and have an inflamed 
base (Fig. 6). 

The lesions of acne are located on the face, the 
shoulders and on the chest and back. True acne rarely 
is found below the free border of the ribs anteriorly or 
posteriorly. 

Together with the acne and the comedones we meet 



64 DISEASES OF THE SKIN 

with milia quite commonly, and the affected parts are 
usually greasy to the feel, showing that the sebaceous 
glands sympathize in the disease. We now have a fair 
picture of a typical case of acne vulgaris. The face, 
back, neck, chest, and shoulders, or all five, are dotted 
over in an irregular manner with blackish points, papules, 
and small pustules; the skin of the nose and forehead 
looks shiny and feels greasy, and perhaps there are some 
milia scattered about the region of the eyes. At times 
the eyes will appear inflamed and hyperemic, especially 
in young, otherwise robust subjects. More commonly 
the complexion will have that pasty appearance indicative 
of what has from old times been called the strumous 
condition. Not unfrequently the skin is abnormally 
red. If the inflammatory process has been unusually 
severe, we may find a considerable amount of scarring. 
Usually acne vulgaris does not leave permanent scars. 
The profuseness of the eruption varies greatly. In some 
cases there will be but a few lesions, while in other cases 
they will be present in vast numbers. This form of 
acne generally occurs in young people. The duration 
of the individual lesion is short, as it soon either dries 
up or discharges its contents. If the papules are squeezed, 
vermicelli-like masses of sebaceous matter will be ex- 
pressed. If the papulopustules are treated in the same 
way, there will first be pressed out a drop or two of pus, 
and then more or less of a sebaceous plug. 

Acne Indurata is a pustular acne in which the pustules 
are of large size and seated upon deeply infiltrated bases. 
They are most commonly sparsely dispersed, and take 
the form of purplish " lumps " of pea to bean size, which 
are hard to the touch. Sometimes they are more readily 
appreciated by touch than by sight, being located deeply 
in the skin. Sometimes they take the form of cutaneous 
abscesses, and if by chance several are located close to 
one another, they may run together and form a raised, 
dark-red, doughy mass. When incised, these lesions 



ACNE IN DU RAT A 65 

sometimes give exit to a large amount of thick pus. 
They usually leave scars, which sometimes are very dis- 
figuring unless they are opened very early in their course. 
It may be the only form of acne present, or it may be 
combined with acne vulgaris. This form of acne usually 
occurs at a more advanced age than does acne vulgaris, 
though it is not unfrequently met with in early life, and 
may persist throughout life. While occurring on the 

Fig. 7 





Acne indurata of the back. 

face, the neck and back are the regions in which it is 
prone to develop in the most marked manner, and to be 
most persistent (Fig. 7). 

Etiology. — Acne is one of the most common of skin 
diseases, and its great predisposing cause is youth. The 
disease first shows itself about the time of puberty and 
manifests a tendency to disappear when the body is 
fully developed — that is, from the twenty-third to the 



66 DISEASES OF THE SKIN 

thirtieth year, although it may continue much later. 
A few rare cases have been reported of acne at an early 
age. Thus, Chambard 1 met with a case in a girl, aged 
six and a half years. The indurated form of acne appears 
later than the simple form, usually after the twenty-fifth 
year. Both sexes are affected, but the disease is more 
frequent in females than in males, and in them begins 
at an earlier age. The period of youth is the time of 
great developmental activity in which the sebaceous 
glands take part, and it is at this time we frequently 
have a seborrhea of the face and other parts. In nearly 
every case of acne the skin of the nose is greasy and 
feels slippery to the touch. This greasy skin is another 
predisposing cause of acne. It provides a favorable 
soil for the growth of the bacillus acnes, which probably 
is the exciting cause of the disease. 

Individuals with thick, pasty, pale skins, with patu- 
lous follicular mouths, are predisposed to acne. These 
peculiarities of skin are met with in scrofulous subjects. 
The disease is less common and severe in negroes than 
in white people. The patulous follicular mouths give 
ready lodgement to foreign matters, and comedones are 
thus formed. This prevents the escape of the follic- 
ular contents, a plug is formed, and we have an acne 
papule or pustule. Comedones are, therefore, an exciting 
cause of acne. 

Heredity has some claim to be regarded as a predis- 
posing cause of acne, but the disease is so common that 
there is no certainty about this factor. 

Digestive disturbances, while not causing acne, are 
most active in aggravating it, as they increase the con- 
gestion of the skin and the seborrheal condition: These 
may take the form of dyspepsia, stomachal or intes- 
tinal; or malassimilation; or failure on the part of the 
liver or pancreas to perform its physiological functions; 
or sluggishness of the large intestine and consequent 

1 Ann. de derm, et de syph., 1878-79, x, 259. 



ACNE INDURATA (37 

constipation. Improper diet, so common in early life, 
is responsible for the maintenance of many cases of 
acne. 

Next to disorders of the digestive organs, those of the 
sexual organs are suposed to have most influence in 
aggravating acne. But inasmuch as most cases of acne 
are amenable to the influence of diet and regulation of 
digestive disorders without any attention being given 
to sexual disorders, it is probable that the latter are 
important etiological factors in comparatively few cases. 
Indeed, it is not improbable that the acne that appears 
on the faces of women at each menstrual period, and at 
that time alone, as well as the aggravation of an already 
existing acne, is due to the more or less pronounced 
disturbance of the digestive organs so frequently observed 
at the same time. In some cases acne does seem to be 
a reflex irritation from the uterus. Amenorrhea is the 
uterine derangement most frequently encountered, but 
that condition is but one evidence of a general constitu- 
tional disorder rather than a disease in itself. 

Masturbation and continence have each been blamed 
as excitants of acne. The former of these of itself does 
not cause acne, but its well-known effects on the nervous, 
moral, and physical condition of growing youths would 
sufficiently account for any part it may have in producing 
acne. There is absolutely no proof that continence 
causes acne. It is safer to say that bad sexual hygiene 
may cause acne, rather than to ascribe it either to 
masturbation on the one hand or to continence on 
the other. 

It may be stated, as a broad, general rule, that anything 
that lowers the general health of the patient contributes 
to the production of acne. We have space to enumerate 
only some of these exciting causes. Thus we have the 
vague state "general debility," anemia and chlorosis, 
oxaluria and uremia, rheumatism and gout, poor circu- 
lation, mental and physical exhaustion, and chronic 



68 DISEASES OF THE SKIN 

malaria. J. Schutz 1 believes that deficient heart action 
and consequent slowness of the circulation are the under- 
lying causes of acne, as they lead to an alteration of the 
sebaceous secretion. 

Pathology. — Acne may begin in the hair follicles or 
in the sebaceous glands, and may be due either to their 
becoming clogged up by inspissated sebum and acting 
like a thorn in the flesh, or to their invasion by micro- 
organisms, either from without or within, which set up 
a suppurative perifolliculitis. The papules of acne are 
located in the upper part of the skin, while the pustules 
are deeper. In very bad cases the follicle may be entirely 
destroyed by the perifolliculitis and scars will be left. 
The sebaceous glands do not take a very active part 
in the process. Microorganisms are found abundantly in 
the suppurating gland cavities. 

In acne indurata we find the hair follicles enormously 
dilated, their orifices filled with corneous cells, and their 
cavities almost converted into cysts. The connective 
tissue about the follicles shows decided signs of inflamma- 
tion, and may be increased in amount. Very often the 
follicles are destroyed by the perifollicular, inflammation. 
When the perifolliculitis is severe and extensive the deep 
layers of the skin become involved, and we have abscess 
formation. 

According to Unna the comedo is not due to stopping 
up of the follicle by extraneous matter, but to a hyper- 
keratosis closing up the follicle mouth, and the black- 
head is due to degeneration of the compressed horny 
cells. Unna, Sabouraud, and Gilchrist each describe 
a special organism as the cause of acne. Unna found a 
flask bacillus and a diplococcus and another bacillus. 
Sabouraud describes still another bacillus as the cause 
of the disease, and believes that the invasion of the infected 
follicles by staphylococci of gray culture produces the 
pustular form Gilchrist's bacillus acnes is pyogenic. 

iArch. f. Dermat, u. Syph., 1900, ii, 323. 



ACNE INDURATA 69 

It is short and thick, straight or curved, and sometimes 
branched. The microorganisms of Sabouraud and Gil- 
christ are identical. The seborrheic skin is the proper 
ground for infection by it. It seems evident, therefore, 
that the disease is parasitic, and this theory best explains 
the course of the disease. As one grows older the charac- 
ter of the skin changes, so that it is no longer a proper 
habitat for the organisms, just as in ringworm of the 
scalp, which undergoes spontaneous recovery after puberty 
is reached. In all pustular lesions the common forms of 
staphylococci are found. 

Diagnosis. — Acne is to be differentiated from rosacea, 
papular and pustular eczema, sycosis, the small pustular 
and tubercular syphilid, and variola. 

Rosacea is due to a dilatation of the bloodvessels, and 
is attended by hyperemia and telangiectases. If there 
are any pustules, they are superficial and due to local 
infection, and if expressed give exit to only a drop of 
pus. Acne is a disease of the sebaceous glands, and 
papules and pustules constitute the disease. They are 
often large, and if expressed will give exit to a plug of 
sebaceous matter and thick pus. Rosacea, as a rule, 
occupies the middle third of the face alone, the forehead, 
nose, and chin. Acne is scattered over the whole face, 
and is often found on the shoulders. 

Papular eczema may occur at any age; acne usually 
occurs between the ages of fifteen and twenty-five. 
Papular eczema rarely is seen on the face alone, and is 
prone to attack the trunk and extremities; acne often 
occurs on the face alone, and is never disseminated over 
the limbs and trunk. In eczema there is an absence 
of comedones; the papules are often surmounted by or 
change into vesicles; they tend to form patches, and the 
disease is very itchy, so that scratch marks are almost 
invariably found. When it gets well it leaves no trace 
on the skin. These symptoms are foreign to acne. 

In pustular eczema, or what has been called impetigo 
simplex, we have a large number of small pustules 



70 DISEASES OF THE SKIN 

running together to form patches which rapid ly become 
covered with greenish or yellow crusts. The disease 
runs a far more acute and stormy course than does acne, 
and is itchy. It is very frequently met with in children, 
whom acne rarely affects. 

Sycosis is a pustular disease affecting the hair follicles 
alone, each pustule being pierced by a hair. Acne occurs 
on the non-hairy as well as the hairy parts, and, indeed, 
shows preference for regions supplied only with rudi- 
mentary hairs. 

Acne necrotica is especially located along the hair line, 
and invades the scalp, which acne never does. It also 
runs a more sluggish course, its papules soften at their 
summits, become surmounted by a small, sunken-in crust, 
which on falling leaves variola-like scars. 

The small pustular syphilid, or syphilitic acne, is a 
general eruption, and it is easy in most cases to obtain 
other evidences of syphilis, such as the remains of the 
initial lesion, enlarged lymphatic glands, mucous patches 
or the like. It is usually more uniform in its lesions, 
and these are plainly papulopustular. The color of the 
areola is more that of raw ham and less inflammatory 
looking than is that of acne. The lesions sometimes 
show a tendency to group into segments of circles, and 
each lesion undergoes a definite development. They 
sometimes leave small, smooth, white scars that may 
disappear in a few months. They are not confined to 
the chest, back, and face, but are scattered over the 
body. The tubercular syphilid could be mistaken for 
an indurated acne. With it there will usually be found 
other evidences of syphilis. The lesions group themselves 
into patches that are kidney-shaped or form segments 
of circles. The tubercles are dark red or raw-ham colored, 
surrounded by a well-marked areola, firm to the touch, 
and do not contain pus. They may ulcerate, or, being 
absorbed, leave pigmented and punched-out cicatrices, 
and, finally, smooth white scars. The scars left by acne 
indurata are puckered and more disfiguring. 



ACNE INDURATA 71 

Variola could scarcely give rise to much doubt, as it 
has well-marked constitutional symptoms, and its lesions 
undergo a definite and characteristic development. 

Treatment. — In the treatment of acne we can obtain 
a cure most rapidly by a combination of internal and 
local treatment. 

We, therefore, begin the treatment of a case by a 
careful inquiry into the general condition of the patient, 
and endeavor to regulate any, even the slightest derange- 
ment of the internal organs. By so doing we may find 
no one of those conditions enumerated under the 
etiology of the affection, and the patient may consider 
himself as in the best condition. Further observation 
will probably reveal some deviation, though slight, from 
perfect health The relief of constitutional disorders 
is conducted according to the principles of general 
medicine, and cannot be given here. Many of the cases 
require cod-liver oil and iron as general measures quite 
apart from any evident disease This is the case in the 
sluggish cases occurring in strumous subjects with pasty 
skins. In plethoric subjects with a good deal of inflam- 
mation attending the acne, laxative agents such as 
yo" grain of calomel in tablet triturates, given three or 
four times a day, will aid in a cure. Whitfield recom- 
mends menthol in 1 to 2 grain doses after each meal to 
subdue gastric reflexes and flushing of the face. 

Diet and hygiene are to be employed rather than 
drugs. It is impossible here to lay down fixed principles 
of diet, and it is better to study each case by itself. A 
good rule is to cut off all sweets, pastry, and cake, and 
give for breakfast and luncheon, or supper, a cereal, but 
not oatmeal, with milk and cream, bread and butter, 
and fruit. For dinner, meat, vegetables, salads with 
plain dressing, and light puddings may be allowed. A 
cup of coffee may be permitted in the morning, but no 
tea or alcoholics. In many cases coffee should not be 
allowed. The food must be well masticated. It must 
be remembered that milk is a food, and that when 



72 DISEASES OF THE SKIN 

other foods are partaken of freely the taking of milk 
at the same time may overload the stomach. The 
omission of milk from the dietary will be of great benefit 
in some cases of acne. Hot water before meals, a glass 
of water at meals, two hours after meals, and on going 
to bed are good directions for the use of beverages. 
Butter may be used freely, and care must be had not to 
restrict the diet too greatly. Many young girls almost 
starve themselves in the mistaken idea that a low diet 
will give them a fine complexion. 

Exercise must be insisted on, an hour or more a day 
being spent in walking, horseback- or bicycle-riding, 
rowing, or other out-door exercise. Daily bathing or 
dry rubbing will keep the skin in healthy condition, 
and Turkish baths are often beneficial. Where a shower 
bath is at hand it is well to have the patient stand in 
about four inches of warm water, and allow the shower to 
fall first warm and then cold; this to be followed by 
brisk rubbing with a coarse bath towel. Where patients 
either cannot or will not take a daily bath, much good 
will be accomplished by having them bathe the chest and 
back daily with cold water and then dry the skin by 
brisk rubbing with a coarse towel. 

There is no drug that can be considered as a specific 
in acne. Arsenic is of use only in very chronic, sluggish 
cases, and the more papular the case the more useful 
the arsenic. It should be used as the last resort, not as the 
first. Fowler's solution is the most frequently used prepara- 
tion in doses of from 3 drops (0.194) three times a day as 
an initial dose, gradually increased to 15 or 20 (1 to 1.33) 
drops or until the appearance of some symptoms of poison- 
ing. Piffard 1 recommends bromide of arsenic in the dose of 
ttTo to 5V grain two or three times a day in rather acute 
cases of acne. A convenient method of administration 
is to make a 2 per cent, solution in alcohol and give 1 
or 2 minims of that in a wineglassful of water. Should 

1 Jour. Cutan. and Ven. Dis., 1884, ii, 71. 



ACNE INDURATA 73 

it cause gastric irritation the dose must be lessened. We 
have used this in a number of cases with good results. 
The sulphid of calcium, has its advocates for sluggish 
pustular cases. It is of doubtful value. Glycerin was 
advocated by Gubler 1 as a cure for acne, and is well 
spoken of by others. It must be given in doses of a 
teaspoonful three times a day increased to a table- 
spoonful, and is of most use in strumous cases. Ergot, 
either the^ fluidextract in doses of \ drachm (2) three 
times a day or a corresponding amount of ergotin, has 
many advocates. 

Small doses of the bichloride of mercury are sometimes 
curative where there is much infiltration. 

Iodide of 'potassium in doses of from 1 to 5 drops (0.065 to 
0.33) of a saturated solution, well diluted, taken three times 
a day before meals, sometimes is useful in pustular acne. 

As acne is a local infection of the skin we have little 
faith in the administration of drugs for its cure except 
to meet symptoms. 

Vaccines often are most efficacious. According to 
Engman: "Initial dose of acne bacillus suspension, 
5,000,000; interval of dose, five to seven days; gradual 
increase of dose to 10,000,000; hot applications dur- 
ing positive phase — forty-eight to seventy- two hours 
after each injection; opening of large, deep lesions forty- 
eight to seventy-two hours after injection, when the walls 
of the little cavities should be rubbed together or so 
manipulated that fresh lymph be induced into and about 
them; after immunity has been established, monthly or 
bimonthly injections should be continued for some time 
to prevent relapse; after immunity has been greatly 
improved, a reactionary inflammation produced by any 
of the numerous pastes is very beneficial. In treating 
acne vulgaris with bacterial suspensions one must be 
certain that the suspensions used are from cultures 
of the acne bacillus, as many short, thin, or fat bacilli 

1 Jour, de Bruxelles, 1870. 



74 DISEASES OF THE SKIN 

are so disguised. If the staphylococcus is prominent in 
the smears from the lesions, 50,000,000 of these should 
be mixed with each dose of the acne suspension. Acne 
vulgaris is primarily a folliculitis and perifolliculitis, 
and of a very chronic character, therefore, lqcal guiding 
influences for the lymph is nearly always necessary." 

The objects of local treatment are to open up the pus- 
tules and papules and allow of the escape of their con- 
tents, to stimulate the skin to a more healthful action, 
and to prevent further infection of the follicles by micro- 
organisms. To attain the first two objects, we may 
employ either a quick or a slow method; to attain the 
last object, we employ an antiparasitic. The best pre- 
ventive local treatment is to keep the skin clean and 
its nutrition good by the use of soap and water. The 
patient is directed to make a thick lather on the skin 
with soap and warm water and to work it into the skin 
for a few minutes with the ends of the fingers. The 
soap is then to be washed off, the skin dried, and wiped 
off with pure alcohol. 

Fig. 




Fox's ring curette. 

An efficient local treatment for very profuse cases of 
acne is to put the skin on the stretch and scrape it some- 
what roughly with a large and long, blunt dermal curette 
with a fenestrated blade (Fig. 8). This tears off the 
tops of all the lesions, presses out the contents of the 
follicles, and stimulates the skin in a most vigorous 
manner. It is followed by some bleeding, which it is 
well to encourage by the use of warm water. Deep 
pustules or cutaneous abscesses, if not emptied by the 
curetting, should be incised. All comedones should be 
squeezed out. The after-treatment consists in washing 
the face with warm water and soap and dusting with 
corn starch, to which may be added oxide of zinc. Instead 



ACNE INDURATA 75 

of this a solution of peroxide of hydrogen or of bichloride 
of mercury, 1 to 1000, or pure alcohol may be dabbed 
on. The scraping is to be repeated two or three times a 
week. The procedure is rough and many patients will 
not endure it. 

After the first scraping the patients do not mind it 
much, and the result is the attainment of a smooth skin 
in a comparatively short time. Twenty-four hours after 
the scraping we may use lotio alba, as given later, or a 
lotion of bichloride of mercury, 1 to 1000, or peroxide of 
hydrogen. 

The same results can be attained in a slower way by 
opening every pustule with an acne lancet (Fig. 9) and 
squeezing out every comedo. This is to be done once or 
twice a week and lotio alba used between times. 

Fig. 9 



Fox's acne lance and dermal curette. 

Very timid patients who will allow no surgical inter- 
ference nor the use of vaccines may be treated according 
to the same principles by directing them to scrub their 
face thoroughly once a day with green soap or tincture of 
green soap, and leave the lather on. After a day or two 
of good scrubbing, sufficient dermatitis will be excited to 
cause the old skin to peel off, while the tops of many of 
the lesions will have been torn off and the skin will have 
been decidedly stimulated. Not until the skin has become 
scaly and feels tense to the patient should a soothing 
ointment be applied. Repeated applications of the soap 
frictions will slowly bring about improvement. Rubbing 
the face with fine sand or coarse corn meal will do good, 
but is not so elegant. 

Massage of the skin is of doubtful value, as it some- 
times seems to spread the disease. The tips of the 
fingers should be dipped in cold cream, and then, pressure 
being exerted by them, the skin of the forehead should be 



70 DISEASES OF THE SKIN 

deeply stroked from the middle line out and over the 
temples. The nose should be stroked from the bridge 
outward and downward. The skin of the cheeks should 
be pinched up and rolled between the fingers and thumb. 
These movements facilitate the emptying of the follicles. 
Stel wagon makes the good suggestion that instead of 
manual massage a small cupping glass with one inch 
opening should be used. 

The application of the galvanic current by means of 
the roller electrode, or by ordinary sponge electrodes, 
will in some sluggish cases prove helpful. G. W. Wende 1 
recommends placing the electrodes in close proximity 
on the face and constantly changing their position 
until the skin becomes reddened. The amount of current 
to be used depends upon the ability of the patient to 
bear pain. Where the skin is very sensitive the anode 
can be held in one place and the face gently stroked 
with the cathode, using 5 to 10 cells for fifteen minutes. 
Stelwagon speaks well of the faradic current where there 
is sluggish muscular tone, using it strong enough to 
produce slight muscular reaction. The high-frequency 
current has its advocates, the glass electrode being used 
both for sparking the individual lesions and for stimu- 
lating the skin by direct application to it. 

The x-rays have proved curative. The treatment 
should never cause more than a slight erythema. The 
single dose method should be employed. It is a dangerous 
method of treatment and should be used only in stubborn 
cases, especially in those leaving scars. The use of the 
Kromayer lamp is also advocated. The first exposure 
should be at 50 cm. distance for one or two minutes. 
Subsequent ones should be given in four or more days on 
the subsidence of the erythema, and may be at shorter 
distance and of longer duration. 

The foregoing methods may be called the mechanical 
treatment of acne. Where they cannot be employed either 

1 Buffalo Med. Jour., 1898-99, xxxviii, 254. 



ACNE INDURATA 77 

because the patient lives at a distance, or cannot attend 
frequently enough, we must resort to the chemical treat- 
ment. 

A vast number of prescriptions have been written 
which are "good for acne/' the majority of which con- 
tain sulphur in some form, and in the strength of \ drachm 
(2) to 1 drachm (4) to the ounce (32), and in ointment 
or lotion form. Sulphur in powder form is good if the 
patient does not mind the odor. The ordinary sulphur 
ointment of the Pharmacopoeia is as good a preparation 
as any. It may be made more elegant by adding some 
perfume, and more efficient by adding 2 per cent, of 
salicylic acid. The sulphuret of potassium may be used 
in the following: 

1$ — Potass, sulphuret., 

Zinci sulphat., aa 5.1 aa 4 

Aquae rosas, ad ^iv 120 M. 

This preparation is commonly spoken of as "lotio alba," 
and is one of the most useful of the compounds of sul- 
phur. It is to be applied two or three times a day, after 
being well shaken. It is often rendered more active by 
adding to it a drachm of precipitated sulphur, and still 
more so if once a day the skin is washed with green soap. 
We have found a modification of this lotion even more 
efficient, the formula of which is: 

1$ — Acid, salicylici, 
Potass, sulphuret., 
Zinci. sulphat., 

Puli. acaciae, aa 3j 4 

Aquae rosae, ad §iv 120 M. 

If the skin becomes inflamed from either of this, cold 
cream should be used for a few days. Kummerf eld's 
lotion composed of: 



i — Sulphur praecipitat., 


5iv 


16 


Pulv. camphor, 


gr. x 


65 


Pulv. tragacanth, 


gr. xx 


133 


Aquae calcis, 






Aquae rosae, 


aa §ij 


60 



is a favorite of manv 



78 DISEASES OF THE SKIN 

Mercurial preparations may be used to more advantage 
in some cases than those of sulphur. It should be borne 
in mind that a mercurial must never be applied to the 
skin until all traces of sulphur are removed, or vice 
versa, because if the precaution is forgotten the black 
sulphide of mercury will be formed, which will give the 
skin the appearance of being sowed with powder grains. 
A lotion of corrosive sublimate, 1 to 2000 to 1 to 1000, 
may be mopped on once or twice a day, or an ointment 
of the protiodide, as recommended by Duhring, may 
be used: 

1$ — Hydrarg. protiodid., gr. v-xv 0.33 toll 

Hydrarg. ammon., gr. x-xxx 0.65 to 21 

Ungt. simplicis, gj 30| M. 

Lassar 1 recommends the following paste- 
ls — /8-naphtol, 10 parts. 
Sulph. praecip., 50 " 
Vaselin., 
Sapo viridis, aa 25 " M. 

This is to be spread upon the skin to the thickness of 
the back of a knife-blade, and left on for fifteen to twenty 
minutes. It is then to be wiped off with a soft cloth, 
and the skin powdered with talc. The skin becomes 
inflamed, turns brown, and peels off. The application 
is to be repeated every day until the skin does peel off. 
Desquamation can be hastened by the application of 
Lassar's paste with 2 per cent, of salicylic acid. 

Resorcin is useful in 20 per cent, aqueous solution 
dabbed on the face two or three times a day until a 
dermatitis is caused. This is allowed to subside under 
cold cream, and when it has subsided the rescorcin 
is to be used again. Ichthyol, the ammoniosulphate, is 
recommeded by Unna for acne, either as a 3 to 5 per 
cent, ointment or as a 3 to 10 per cent, aqueous solution. 
As much as 15 grains (1) of it are to be taken by the 
mouth during the day in divided doses. A mild corro- 

1 Therap. Monatshefte, 1887, No. 1. 



ACXE INDURATA 79 

sive sublimate wash is to be applied to the face until 
the patient goes to bed, and then a 10 per cent, aqueous 
solution, or paste of ichthyol is to be kept on until morn- 
ing. Startin 1 has employed local steam baths by means 
of a steam atomizer, with success. The steaming should 
be kept up for twenty to thirty minutes, and tincture of 
benzoin used in the medicine cup. While useful in some 
cases it does harm in other cases. 

The foregoing remedies are all especially adapted to 
more or less sluggish cases, the type met with in the 
great majority of instances. In very recent and quite 
inflammatory cases, besides the administration of laxa- 
tives and the regulation of the diet, the patient should 
be directed to bathe the face with hot water, either with 
or without the addition of borax (5ij to Oj), and apply 
a soothing ointment. When the inflammatory symptoms 
subside, recourse must be had to some of the above 
detailed methods of treatment. 

Bathing of the face with hot water before the appli- 
cation of any lotion or ointment should be advised. In 
indurated acne, where cutaneous abscesses have formed 
and the lesions are discrete, each abscess will have to be 
opened up with a lancet, the contents of the abscess 
discharged, and carbolic acid, either pure or diluted, 
introduced, by means of a little cotton around the end 
of a sharpened bit of wood, into the abscess cavity, so 
as to destroy the lining membrane. 

Individual acne lesions can sometimes be aborted by 
touching them with pure carbolic acid or acid nitrate of 
mercury. 

Prognosis. — By persistent effort and careful regula- 
tion of all the bodily functions a great improvement 
can be effected, one fairly deserving the name of cure. 
But it is often hard to prevent the occasional appearance 
of a few acne lesions until the period of life in which 
acne usually occurs is passed. There are some cases in 

1 Lancet, 1SS9, i, 934. 



80 DISEASES OF THE SKIN 

which we can do but little because we are unable to 
remove the underlying cause. 

Acne Artificialis. — By this term is meant an inflam- 
mation of the sebaceous glands and hair follicles caused 
by drugs either applied locally or acting from within. It 
has three principal varieties, namely, tar acne, bromic 
acne, and iodic acne, and should be regarded rather as a 
dermatitis medicamentosa than as an acne. Tar pro- 
duces acne-like lesions with black points when applied 
locally to some susceptible skins. As a rule, papules 
are more abundant than pustules, but abscesses and 
furuncles may form. These lesions are not confined to 
the usual locations for acne, are particularly abundant 
on the extensor surface of the arms, and are recognizable 
by their central black points and by the fact that the 
patient is using tar. For its cure all that is necessary 
is to stop the use of the tar and to soothe the inflamed 
skin. None of these acnes is a true one. Bromic and 
iodic acne will be spoken of under drug eruptions. Deriva- 
tives of tar, chrysarobin and pyrogallol may also produce 
similar acne-like lesions when applied externally. 

Acne Atrophica is a term applied to the scars left by 
acne, and to acne necrotica. The first needs no descrip- 
tion; the second will be found further on. 

Acne Cachecticorum is rather to be regarded as a scrof- 
uloderm than an acne, as it probably has little to do 
with the sebaceous glands. It occurs in broken-down or 
scrofulous subjects, and is particularly prone to appear 
upon the extremities, though it may be disseminated 
over the whole body. It takes the form of small, congested 
or dark-red, sluggish, flat papules and papulopustules 
that run a slow course, break down, perhaps ulcerate, 
and leave small depressed cicatrices. They may aggre- 
gate into patches. Occurring on the fingers, these will 
often be congested and clubbed. The lesions may appear 
in crops. It occurs in children as well as in adults. 
It is one of the rare forms of the disease, and requires 



ACNE NECROTICA 81 

tonic remedies, such as cod-liver oil and iron, for its 
cure. 

Acne Frontalis. — See Acne necrotica. 

Acne Hypertrophic a. — See Rosacea. 

Acne, Iodic and Bromic. — See Dermatitis medicamentosa. 

Acne Keloid. — See Dermatitis papillaris capillitii. 

Acne Keratosa. — H. R. Crocker describes this disease 
as an eruption of finger-nail sized, well-defined, excoriated 
patches covered with blood crusts located on the cheeks 
and chin, especially near the mouth. It leaves white, 
hard scars. It is usually a symmetrical eruption, but 
the lesions may come out singly or in very small num- 
bers at irregular intervals. The individual lesion begins 
as a red, firm, tender nodule upon which a pustule forms 
and dries into a scab. Embedded in the lesion are 
one or more horny or soft conical plugs about y\- inch 
long, which give rise to irritation until removed. When 
removed the lesion heals slowly after weeks or months. 
The disease is chronic, showing no tendency to recovery. 
Thus far, treatment has been unavailing. 

Acne Medicamentosa. — See Dermatitis medicamentosa. 

Acne Necrotica. — Synonyms: A. agminata; A. frontalis; 
A. varioliformis; A. pilaris; A. rodens; A. telangiec- 
todes; A. ulcereuse; A. arthritique; A. miliaire scrof- 
uleuse; Lupoid acne; Hydradenitis destruens suppurativa; 
Acnitis. 

The disease begins by the eruption of a few flattened, 
red, firm papules with a red border which in a few hours 
have pale-yellow centres looking like pustules, but which 
are crusts. The papules may be the size of a head of 
a pin or that of a lentil. The crusts are 2 to 4 mm. 
in diameter. At first yellow they soon become brown. 
If the crust is raised, it discloses a deep, cup-shaped 
depression with rugose walls. There is a delicate layer 
of pus between the crust and the bottom of the depres- 
sion. Left to itself, the crust falls after many weeks, 
6 



82 DISEASES OF THE SKIN 

leaving a red, dry depression, which after a time becomes 
white, resembling variola scars. The lesions show a ten- 
dency to group. If the disease occurs on hairy regions 
it destroys the hair. Sometimes the original crust enlarges 
by the formation of a second vesicle about the first, 
or two vesicles near each other may fuse. If scratched, 
they may become impetiginous. The sites of pre- 
dilection for the disease are the nose, temples, forehead, 
between the shoulder-blades, and over the breast bone. 
It is most often seen on the temples along the hair, 
and may spread on the scalp or bearded portion of the 
face, causing destruction of the hair. The disease may 
occur on the limbs. It is not seen before puberty, and 
continues indefinitely or by relapses in one place or in 
several, often symmetrical regions. A seborrhea may 
precede and accompany the disease. 

Etiology. — The cause of the disease is not deter- 
mined. It occurs about equally in men and women, 
who usually are over thirty years of age and in poor 
circumstances. Sabouraud believes that a seborrheal 
skin is the predisposing factor, and that the micro- 
bacillus is the cause of the disease. The Staphylococcus 
aureus is also found in connection with it. By some it 
is thought to be a tuberculid, due to the toxins of tubercle 
bacilli. 

Pathology. — J. A. Fordyce 1 finds that the disease 
begins in and about the hair follicles above the entrance 
of the sebaceous glands. As the inflammatory process 
extends it involves the sebaceous glands as well as the 
superficial portion of the derma, resulting in a necrosis 
of the pilosebaceous system. In one case he found 
enormous numbers of staphylococci in the lymph spaces 
and free in the tissues. 

Diagnosis. — In some cases the resemblance to syphilis 
is striking, but the extreme chronicity of it and its occur- 
rence along the hair line distinguish it, as well as its 

1 Jour. Cutan. and Gen.-Urin. Dis., 1894, xii., 152. 



ACNE URTICATA S3 

general course of development. It differs from acne in 
leaving varioliform scars, in its sluggish course, and in 
invading the scalp. 

Treatment. — The ointment of the ammoniate of 
mercury is efficient in many cases. Sulphur 10 per 
cent., salicylic acid 3 to 5 per cent., and resorcin 1 to 
5 per cent., in ointment are also useful. Curetting is 
of service. Sabouraud thinks that for the disease when 
it invades the scalp the best remedy is pyrogallol, either 
with or without tar or sulphur, 15 per cent, in ointment, 
or 6 per cent, in ethereal oil. He also advocates the daily 
use of alcohol with a little iodin or bichloride of mer- 
cury for three months after the disease is apparently 
well. Stelwagon has found a lotion of resorcin in a 
saturated solution of boric acid best for non-hairy regions 
conjoined with ammoniate of mercury for hairy regions. 
Crocker speaks highly of the administration of 15 to 
25 drops of chloride of iron three times a day; and also 
of iodide of potassium. Engrnan advocates the use of 
vaccines. He says: Here the staphylococcus is deep in 
the corium at the base of the follicle and readily acces- 
sible to the lymph, and therefore frequently shows 
clinical results after one injection. The injections in 
this disease should be from 50,000,000 to 100,000,000 at 
four days' interval. 

Acne Necrotisans et Exulcerans Serpiginosa Nasi is 
described by Kaposi as an eruption of flabby papules as 
large as a pin's head upon the end of the nose that soon 
undergo purulent or necrotic degeneration and leave 
deep scars. New lesions appear and in a few weeks or 
months the end of the nose is destroyed. 

Acne Punctata. — See Comedo. 

Acne Rosacea. — See Rosacea. 

Acne Scrofulosorum. — See Acne cachecticorum. 

Acne Urticata is the name given by Kaposi to a chronic, 
itching disease occurring on the face, scalp, hands, and, 



84 DISEASES OF THE SKIN 

usually, on the extensor surfaces of the extremities. It 
begins as an acute eruption of bean or larger size, 
pale-red, very hard, wheal-like elevations, which within 
a few hours to four days undergo involution. They are 
usually scratched and broken. They leave flat, brown, 
cicatricial stripes corresponding to the scratches. The 
itching is so severe as to interfere with sleeping. There 
seems to be no good reason for regarding this as a 
distinct disease. It is really a form of urticaria. 

Acne Varioliformis. — See Molluscum contagiosum and 
Acne necrotica. 

Acnitis. — See Acne necrotica. 
Acrochordon. — See Fibroma. 

Acrodermatitis Chronica Atrophicans. — A rare disease 
that begins on the hands and slowly spreads up the arms. 
It begins as small crimson or purplish-red nodules look- 
ing like chilblains, which later become atrophic, thin, 
and wrinkled. Its course is chronic and the treatment 
unavailing. 

Acrodermatitis Perstans. — This disease was first de- 
scribed by Hallopeau. It always begins upon the ends of 
the fingers as more or less extensive flattened pustules 
deep in the epidermis. Over them the epidermis exfoli- 
ates, and at last an eroded surface is left. In some cases 
a whitlow precedes them, in some an injury, but many 
come spontaneously. The nails are involved in whole 
or in part. At last the ends of the fingers become 
shrunken, lose their nails, and become little conical, 
sclerosed stumps. From the fingers the disease extends 
upon the palms and backs of the hands. The feet may 
be involved, but less profoundly, and the disease may 
occur elsewhere on the body, although rarely. There 
may be subjective symptoms of moderate pruritus and 
local pain which may be severe and radiate up the arm. 
The disease is progressive and incurable. It is probably 
a neuritis. It occurs both in men and women. 



ACTINOMYCOSIS 85 

Acrodynia, or Erythema epidemicum, is a disease 
closely allied to pellagra in its symptoms, that has been 
observed chiefly among French and Belgian soldiers, 
and is probably due to some defect in food supplies. 
It begins with gastro-intestinal irritation, to which 
certain neuroses soon add themselves, such as formica- 
tion, hyperesthesia, and anesthesia. An erythema of 
the hands and feet, and it may be of the whole body, 
followed by desquamation or by brown or black pigmenta- 
tion, is the cutaneous element of the disease. Recovery 
usually takes place, although death may occur from 
diarrhea. 

Acromegaly. — A disease characterized by overgrowth 
of the bones and soft tissues of the face, hands, wrists, 
and feet. It is a rare condition and is allied to elephan- 
tiasis. It is a progressive and, usually, symmetrical 
disease, and at times attains immense proportions 
involving the whole body. The skin becomes dry and 
harsh, yellowish and wrinkled. Fibromas may develop. 
Symptoms of nervous derangement are also present. 
The cause is unknown. The treatment is on general 
principles. Counter-irritation over the spine is advised. 

Actinomycosis. — While this is usually a disease of 
cattle, in which it causes tumors of the jaws, it may 
attack man and produce nodular tumors with fistulous 
openings. It is due to the invasion of the tissues by the 
ray fungus. Infection usually occurs by the mouth 
along a carious tooth, but it may take place through 
the digestive tract, the lungs, and, rarely, by an abrasion 
of the skin. The incubation period may be weeks, 
months, or years. The tumors bear a strong resemblance 
to sarcoma and are livid or bluish red. At first firm, 
they after a time soften and break down and discharge 
through a fistulous tract, at first a purulent, afterward a 
sanious material, in which are numerous yellow granules, 
from pinhead to hemp-seed size. The affected area 
becomes infiltrated, swollen, reddish, and studded with 



86 DISEASES OF THE SKIN 

a number of nodules that in their turn show fistulous 
openings from which come the characteristic discharge. 
They are most often seen on the face and neck, but may 
occur on the chest and abdomen. The disease runs a 
chronic course usually without constitutional disturbance. 

The fungus which causes the disease in the ray fungus, 
or actinomyces, which consists of a central mass of inter- 
twining threads from w^hich branch the mycelia-like rays, 
hence its name. The mycelia terminate in bulbous ends. 
The diagnosis from sarcoma, tuberculous swellings, syph- 
ilis, and mycetoma is made by the location about the jaws, 
the fistulous openings, and especially the finding of the 
fungus. Its prognosis is good if taken early and properly 
treated. Otherwise it is bad. 

Iodide of potassium in 10 to 15 grain (0.66 to 1) doses, 
three times a day increased to 30 grains (2), should be 
given, and continued for some time after the patient is 
apparently well. It may be combined with the insertion 
into the sinuses of a 1 per cent, solution of the same 
drug. Sulphate of copper in i grain dose four times a 
day may be tried. Surgical procedures may be resorted 
to at the same time that the iodide is administered. 

Addison's Keloid. — See Morphea. 

Adenocarcinoma is a carcinoma originating in the 
glands of the skin, most often in the sweat glands. 

Adenoma. — These are glandular tumors, and are due to 
a proliferation of the lining cells of either the sebaceous 
or sweat glands. There are, therefore, two varieties: 
A. sebaceum and A. sudoriferum. Though met with in 
persons of mature years, it is not improbable that they 
are congenital defects. They form solid tumors from 
pinhead to egg size or larger. They may remain station- 
ary or grow; may disappear spontaneously, ulcerate, 
form cysts, or undergo hyaline, colloid, or fatty degenera- 
tion. While usually benign, they may become malignant. 
They tend to relapse after extirpation. 




Adenoma Sebaceum. (Pizzoli.) 



AINHUM 87 

The sebaceous form is encountered most often on the 
face, about the nose and mouth; less frequently upon the 
scalp, but may occur anywhere. While usually symmet- 
rical in distribution, it may be unilateral.. The lesions 
are rounded papules varying from a pin's head to a split 
pea in size, and usually occur in groups. The color of 
these adenomas varies from pale yellow to red, when 
they will have fine telangiectases over them. They 
occur most often in women, and in early life are generally 
multiple, often with an uneven surface, and seated deep 
in the skin. Once having appeared they do not tend to 
change, though a few may undergo involution and leave 
atrophic scars. The patients usually have coarse skins, 
often are mentally deficient, and also frequently present 
comedones, nevi, fibromas, and other defects scattered 
about the trunk and limbs. They seem to belong rather 
to the class of nevus than true adenomas. Politzer 
has cured one case of the sebaceous variety by means 
of multiple scarifications. Crocker advises electrolysis. 
A resorcin healing paste may be tried. 

The sudoriferous variety occurs upon the head, neck, 
and extremities as dirty grayish-white, pea- to egg-sized 
tumors, sometimes in groups, with uneven, often knobby 
surface. When they develop from the coil they are called 
adenoma sudoriparum or spiradenoma; when from the 
duct, syringadenoma. They are rare lesions of the skin, 
difficult of diagnosis, and require extirpation or total 
destruction for their cure. Most cases formerly described 
under this heading are now regarded as cases of multiple 
benign cystic epithelioma, which see. 

Ainhum is a disease most frequently seen in the negro 
race, though a number of cases have been reported from 
India. It is seen in men more often than women, and 
several members of the same family have been known to 
be affected by it. The little toe of one or both feet is 
the one usually diseased, though the other toes do not 
always escape. It begins as a furrow on the inner and 



88 DISEASES OF THE SKIN 

lower side of the proximal end of the toe, which gradu- 
ally extends outward and upward so as to encircle the 
whole toe at its juncture with the foot. In the mean- 
time the toe becomes enlarged, separates from its next 
neighbor, and rotates outward. When fully developed 
the toe wobbles about so that it interferes with walking. 
The whole process is unattended with ulceration, except 
accidentally caused, and after the disease has lasted a 
long time. When it occurs the toe falls off. There is 
little pain experienced until near the end of the disease. 
The fingers also rarely may be affected. It takes from 
one to fifteen years for the full development of the 
disease. The cause is unknown, though traumatism 
probably plays a part. The process is one of progressive 
degeneration and destruction of all the elements of the 
toe — skin, muscles, bone. In its early stage a deep 
incision perpendicular to the direction of the furrow may 
check its course. Later, amputation is required for the 
cure, and healing takes place rapidly. 

Albinism. — This is a congenital defect of pigment 
which may be partial or complete. The skin is milky 
white in color, or pinkish. If it affects the hairy parts 
the hair is white or yellowish white. The pupils of the 
eyes are red, owing to an absence of pigment from the 
choroid. The subjects of complete albinism are not 
robust. Heredity is a cause. Adrian 1 has found con- 
sanguinity in the parents in some cases. It occurs both 
in negroes and white people. There is no treatment for 
the disease. 

Aleppo Boil, Bouton, Aleppo Evil, or Oriental Sore 
is an ill-defined furuncular disease occurrying in Syria 
and the Levant, where it is endemic and widespread. 
One or more itchy red papules appear that, after some 
time, change into pea- or bean-sized pustules, grow 
slowly, and ulcerate indolently. Large ulcerating, granu- 

Dermat, Centralbl., 1906, ix, 258. 



ALOPECIA ADNATA 89 

lating patches may form by the coalescence of neigh- 
boring pustules. The ulcers are sharply defined and 
irregular in shape, and when crusted may resemble 
syphilitic rupia. Healing takes place after months, 
leaving a pigmented and contracted scar. The ulcer 
may heal at one part and extend at another. The disease 
is painless. In uncomplicated cases the prognosis is 
good. The extremities and face are the parts most 
often affected. All ages and conditions contract the 
disease. One attack usually protects against subsequent 
infection. It is due to infection, probably by a parasite, 
called by Wright, "Helcosoma tropica." P. G. Woolley 1 
recommends J grain doses of sulphate of copper for the 
treatment of the disease. Painting the papules with 
tincture of iodin is recommended, as is scraping out the 
pustules with the curette and applying nitric acid. 
Spraying the ulcers with distilled very hot water, and 
keeping them covered with dry aseptic gauze has given 
good results. Ulcers are to be treated on surgical prin- 
ciples. 

Alopecia. — Synonyms: Calvities; (Fr.) Alopecie; (Ger.) 
Kahlheit; (Ital.) Calvezza; (Sp.) Calvez; Baldness. 

By alopecia is meant a partial or general loss of the 
hair, so as to produce a noticeable thinning or a bare spot. 
There are four main varieties, namely: Alopecia adnata; 
Alopecia senilis; Alopecia prematura or presenilis; and 
Alopecia areata. 

Alopecia, Adnata is congenital baldness, and is a rare 
affection. 

Symptoms. — The newborn child is covered with long, 
dark hair which soon falls to give place to fine lanugo 
hairs; or this change has taken place before birth, the 
usual course of events, and at birth lanugo hairs only are 
present. In alopecia adnata there is not the slightest 
trace even of lanugo hairs either on the scalp or eyebrows. 

1 Jour. Amer. Med. Assoc, 1907, xlviii, 789. 



90 DISEASES OF THE SKIN 

In some cases the baldness is not so complete. Most 
cases, after months or years, recover either altogether or 
partially, but in some cases the hair never grows. In 
pronounced cases delayed dentition or deficiency of the 
teeth has been observed. 

Etiology. — The cause of the disease is arrest of the 
development of the hair, probably due to an error in 
innervation. It is hereditary in some families. 

Pathology. — There is a complete absence both of hair 
and hair papilla. There are some abortive hair follicles. 
Otherwise the scalp is normal. 

Treatment. — The treatment is mainly an expectant 
one. The nutrition of the child should be looked after 
and the scalp kept in a healthy condition. If this expect- 
ant plan does not satisfy the child's attendants, some of 
the stimulating hair lotions, as in alopecia presenilis, 
may be prescribed for the moral effect upon them. 

Alopecia Senilis is baldness occurring in advancing 
years. Any loss of hair commencing about the forty- 
fifth year and without apparent cause may be placed 
under this heading. Graying of the hair may have 
preceded it for several years or may be coincident with 
it. Or the hair may fall without becoming gray. The 
hair fall having once begun is progressive, though its 
rate of progress may be slow or fast. It usually shows 
itself first upon the vertex of the head, forming the ton- 
sure, which slowly increases in size and, moving forward, 
renders the whole top of the head bald. Or it may begin 
anteriorly and move backward. Or the hair on the 
whole top of the head may become thinned at once. 
Rarely are the temporal and occipital regions bald, and 
an island or tuft of hair is sometimes preserved for a 
long time in the middle frontal region. The hair fall is 
always symmetrical and the bare scalp is smooth, oily, 
shiny, and appears as if stretched. Not only does the 
hair fall from the scalp, but it may fall from the axilla 
and pubic region; these manifestations being more 



ALOPECIA PREMATURA 91 

common in women than men. Very rarely does the 
beard fall. 

Etiology. — The cause of this form of baldness is a 
progressive atrophy of the scalp. Men are far more 
prone to the disease than are women. 

Treatment. — As to the treatment we can do nothing. 
Prophylaxis, as described under Alopecia prematura, 
will delay its onset. 

Alopecia Prematura is baldness occurring before middle 
life. It may be idiopathic or symptomatic. 

Alopecia prematura idiopathica arises without any 
evident disease of the scalp or disorder of the general 
health. It usually begins in early life, between twenty-five 
and thirty-five; it may begin as early as the eighteenth 
year. Its general course is the same as the senile form 
of alopecia. Very often the upper parts of the temples 
are earliest affected, the hair line receding. In those 
who part the hair in the middle, the thinning of the 
hair about the part may be the first thing to attract 
attention. The process of the hair fall is one of progres- 
sive thinning of the individual hairs at first, and then of 
the whole quantity of hair, so that strong hairs give place 
to lanugo hairs, and these in turn fall and leave bald 
places. At the same time a progressive tightening of the 
scalp upon the skull will be observable in some cases, 
the scalp having lost that cushion of fat that is under it 
in early life. The hair fall having begun is progressive, 
though years may elapse before there is absolute baldness. 
The tonsure may not enlarge for a long time, and then 
increase rapidly in size. 

Etiology. — The main cause of this form of baldness 
is heredity. Fathers and sons for generations may grow 
bald early, or the inherited peculiarity may have to 
be traced to the grandparents or some collateral line. 
Not all the children of one family in which baldness is 
hereditary are bald, but it will manifest itself in two 
or three of them. According to Pincus, 1 inheritance and 

1 Virchow's Archiv, 1867, xli, 322. 



92 DISEASES OF THE SKIN 

chronic eczema or an impetiginous eruption on the 
scalp in the years preceding puberty are the only pre- 
disposing causes of baldness. Insufficient or improper 
care of the scalp; daily sousing of the hair with water, 
combined with improper drying of the hair afterward; 
sweating o£ the head, either spontaneously or on account 
of the wearing of unventilated or hot head-coverings; 
constant mental strain, either on .account of intellectual 
work or of worry; the wearing of stiff, unyielding hats; 
gout; all diseases lowering the general nutrition, and 
dissipation are all put forth by reputable observers as 
causes of premature baldness. 

That women are less often bald than men probably 
depends upon several factors: The fatty cushion beneath 
their scalps is longer preserved than in men; they give 
more attention to the care of the hair and less often wet 
it; and their hats are soft, ventilated, and fit loosely. 

Prognosis. — The prognosis of this form of baldness 
is bad, and especially so if the disease is hereditary and 
the patient is more than thirty years of age. It is better 
with women than with men, as they will give more time 
to the care of their scalps and show less tendency to 
alopecia. 

Treatment. — We can do more for this form of bald- 
ness by prophylaxis than by attempts at making the hair 
that has fallen out grow in again. Prophylaxis should 
begin at the beginning of life, and should be continuous. 
This is of special importance in the case of children in 
families prone to early loss of hair. 

The hygiene of the scalp is the chief part of the prophyl- 
actic treatment. Beginning in infancy, the scalp should 
be gently cleansed of the vernix caseosa and other extra- 
neous substances that have gathered on it during the 
process of parturition. This should be done by the gentle 
use of soap and water after rubbing in a little sweet 
almond or other bland oil. No force should be used, 
and after the scalp is washed it should be patted dry 



ALOPECIA PREMATURA 93 

with a soft, warm cloth, and a little oil or vaselin 
smeared over it. After the first washing it should be 
oiled daily and washed every second day. When the 
hair begins to grow, a soft brush alone should be used to 
arrange it, and the daily oiling may be stopped, unless 
sebaceous matter accumulates in cakes, in which event 
the oiling should be continued. Sometimes it is well to 
add a little sulphur to the oil or vaselin, but in most 
cases it is unnecessary. The slightest indication of disease 
of the scalp should be promptly and properly dealt with. 
A child's hair should be cut short, not cropped close to 
the head. After a girl has reached her eighth or ninth 
year the hair should be allowed to grow. 

The hair and scalp do not need to be washed more 
than once in two or three weeks, and for this purpose 
any good soap will do, with plenty of water to wash out 
the soap-suds. Borax with water will clean the scalp 
nicely, but its continuous use is injurious. The yolk of 
three eggs beaten up with lime-water makes an elegant 
shampoo. The daily sousing of the head in water should 
be prohibited. Deep brushing of the hair with a long- 
bristled brush of sufficient stiffness to warm, but not 
scratch, the scalp is one of the best agents we have for 
stimulating the hair. The brushing should be done daily 
and systematically. 

Pomades and hair lotions should be avoided unless 
there is some evident disease of the scalp. Women 
should be cautioned against pulling their hair into arti- 
ficial and constrained positions. It is most important 
that a sufficient amount of out-door exercise should be 
taken to aid in keeping the patient in good general 
condition. 

When the hair has begun to fall it is important that 
the hygiene of the scalp should be begun, if not already 
practised. We can do more for our cases in this way 
than by any other method. 

Many remedies have been advised for the curative treat- 
ment of baldness. Pilocarpin, in hypodermic injections or 



gr. vij 


50 


5ij 


50 


Svj 


200 



94 DISEASES OF THE SKIN 

in ointment form, has been warmly commended. Lassar 1 
prescribes it as follows: 

1$ — Hydrochlorate of pilocarpin, gr. xxx 2 

Vaselin, 5v 20 

Lanolin, ad §ij ad 60 

Oil of lavender, gtt. xxv 1 66 M. 

It may also be used in the form of the fluidextract of 
pilocarpus, 10 to 15 per cent, strength, in dilute alcohol. 
He also advises oil of turpentine, equal parts with an 
indifferent oil or alcohol. Another useful formula for 
pilocarpin is that of Sabouraud: 

1$ — Pilocarpin muriat., 
Aquse rosse, 
Alcohol, 
^Etheris, 
Spts. lavendulse, aa 3vj 25 M. 

This is to be well rubbed in morning and night. Gallic 
acid, 3 per cent., in an oily excipient; tar; galvanism; 
massage; tincture of cantharides (3 j to 5 j), tincture of nux 
vomica (3 j to 5 j), and a lot of other irritants and essential 
oils have their advocates. Our experience teaches us that 
so-called "hair tonics" are of little value, and that the 
best remedies are attention to the general health of the 
patient, massage of the scalp, and daily systematic and 
deep brushing of the hair. Pilocarpin is the only drug 
that has shown any decided influence on hair growth. 
Electricity is recommended by Stelwagon, either static, 
by means of the crown, quite near the scalp, for five 
minutes; or faradic, with the metallic brush or comb. 
The high-frequency current, D'Arsonval, is also worthy 
of a trial. It should be used about three times a week, 
with enough vigor to produce redness of the scalp, using 
either the hollow glass electrode or one filled with 
powdered carbon. 

Alopecia Prematura Symptomatica is premature baldness 
in which there is some evident disease of the scalp or 
disorder of the general nutrition of the body to account 

1 Therap. Monatshefte, 1888, No. 12. 



ALOPECIA PITYRODES 95 

for it. It has four varieties: Alopecia furfuracea seu 
pityrodes, A. syphilitica, Defluvium capillorum, and A. 
follicularis. 

Alopecia Pityrodes seu Seborrhoica is the form most 
frequently met with and the one in which we can often 
obtain good results by treatment. In our experience 70 
per cent, of all cases of loss of hair are of this variety. 

Symptoms. — In alopecia pityrodes we have an evident 
disease of the scalp to deal with — that is, dandruff. By 
this we mean either a seborrheal dermatitis with fatty 
crusts, or else pityriasis with more or less abundant 
scaling. In some cases the condition is one of seborrhea 
with extreme oiliness of the scalp and hair and no scales. 
In others we meet with pityriasis steatoides with abundant 
heaping up of fatty scales. 

Alopecia pityrodes has two stages: The first one lasts 
from two to seven years or more, and is attended with 
a greater or lesser amount of dandruff and by dryness of 
the hair. Then comes the second stage, when the hair 
falls more or less rapidly. Its course may be the same 
as that of the two previously described forms of baldness, 
though more commonly the whole top of the head is 
affected at once, the hair becoming progressively thinner 
in diameter and less in amount until baldness results. 
As the baldness increases the dandruff lessens. The 
disease is one of early life in a large number of cases, 
often occurring between the twentieth and thirtieth 
year. While both men and women lose their hair from 
dandruff, it is quite exceptional for a woman to become 
absolutely bald like a man. 

If the condition is one of seborrheal dermatitis there 
will be more or less redness of the scalp. While if pity- 
riasis steatoides is present the hair will be oily. The 
general course of the alopecia is the same as in the dry 
form. Itching is often complained of. 

Etiology. — The greatest predisposing cause of the 
hair fall is heredity. Not that one inherits baldness, 



96 DISEASES OF THE SKIN 

but a weakness of resistance to the exciting cause, a 
seborrhea or pityriasis. Anything that lowers the general 
nutrition of the patient acts in a similar manner. The 
chief exciting cause is the infection of the scalp with some 
form of dandruff. By this it is not meant that everyone 
who has dandruff will become bald. But that in certain 
persons when the scalp becomes diseased, the hair follicles 
become so likewise, and after a time the hair production 
ceases. There is little doubt but that alopecia pityrodes 
is contagious, and the experiments of Lassar and Bishop 1 
would seem to prove this. They succeeded in producing 
typical alopecia pityrodes in guinea-pigs by rubbing into 
their backs a pomade composed of the scales taken from 
the head of a student who was afflicted with the same 
disease. A number of observers have reported from 
time to time the finding of a parasite in alopecia, for an 
account of which the reader is referred to the sections on 
seborrhea and pityriasis. 

Treatment. — The treatment of this form of baldness 
must be addressed to the cure of the seborrhea or pity- 
riasis that causes the loss of hair and to improvement 
of the nutrition of the patient. Prophylaxis is here 
again more important than the use of remedies for 
promoting the growth of the hair. The treatment of 
seborrhea 'and pityriasis will be considered under their 
respective headings, and need not be here detailed. 
The mistake is frequently made of prescribing tincture of 
cantharides or other irritant because the hair falls. Of 
course, these things, in an already more or less inflamed 
scalp, only do harm. If we can succeed in curing the 
seborrhea or pityriasis, the hair will take care of itself. 
If the case comes to us before absolute baldness is 
established, we can feel pretty confident that we can 
stop, or at least delay, the fall of the hair. But we must 
inform our patients that it is only by long and persistent 
treatment that we can accomplish anything. 

The drugs that are of most use are resorcin, sulphur, 

1 Monatshefte f. prakt. Dermat., 1882, i, 131. 



ALOPECIA PITYRODES 97 

tar, and mercury. They should be employed until the 
seborrhea or pityriasis are checked. When that is accom- 
plished, pilocarpin and other remedies as given under 
alopecia prematura idiopathica are to be used. It is 
often well to add resorcin to the pilocarpin lotion for 
subsequent treatment. 

Resorcin may be prescribed as follows: 

1$ — Resorcin, 3J 4 

01. ricini, gtt. v 33 

Spts. vini rect., ad giv ad 120 M. 

Bichloride of mercury is often added to this, 1 or 2 
grains (0.06 to 0.13) to the ounce (30), such as in White's 
formula : 

1$ — Hydrarg. bichlor., gr. iv 24 

Resorcin vel., 
Euresol pro capillis, 
Spts. formicari, 
01. ricini, 
Alcohol, 70 per cent., ad gviij 250, M. 

These lotions are to be applied morning and night. 

Tar is a good remedy, but it is objectionable on account 
of its odor and color. It may be used in the form of an 
ointment 1 or 2 drams (4 to 8) to the ounce (32) or of 
the same strength in an oil. Joseph's lotion is: 

R< — Anthrasol, gr. xlv 3 

01. aurant. flor., gtt. iv 

Tinct. saponis viridis, gj 30 

Alcohol, ad gv 150 M. 

Sabouraud advises: 

R— 01. cadini. giij . 100 

Decoct, quillaquse, gj 30 
Yolk of egg, No. j 

Aq. destil., q. s. ad gviij 250 j M. 

Sulphur is the most reliable remedy, in the proportion of 
1 to 2 drachms (4 to 8) to the ounce, (32) and the best way 
of using sulphur is in unguentum aquse rosae or cold cream. 
A very elegant sulphur ointment is: 



3ij 


8 


Sj 


32 


3j-nj 


4 to 12 


Sviij 


250 



-Cerse albse, 


ovij 


28 




01. petrolati, 


gv 


155 




Aquae rosse, 


giiss • 


75 




Sodse biborat., 


gr. xxxvj 


2 34 


Sulphur, prascipitat., 


3vij 


28 


M 



98 DISEASES OF THE SKIN 

This is known as "Sulphur Cream." If there is much 
pityriasis or seborrhea the patient should be directed 
to shampoo the scalp and, when it is dry, to rub in the 
sulphur pomade. The next three nights he should 
use the pomade, and then the scalp should be washed, 
and after drying the ointment applied. For the next 
ten days the ointment should be used every other day, 
and then the scalp washed. When this has been kept up 
for three months a drachm of oil of cade may be added 
to the sulphur pomade and used twice a week. If the 
smell of the tar is objectionable, the sulphur pomade alone 
may be continued. Further particulars in regard to the 
treatment of seborrheal dermatitis will be found under 
the section upon that subject. 

When there is absolute baldness it is questionable if 
anything will make the hair grow. 

Alopecia Syphilitica may be an early or late manifes- 
tation of syphilis; it occurs both in benign and malignant 
cases, and manifests itself as a more or less general and 
temporary hair fall, or as a localized, destructive, and 
permanent one. 

Symptoms. — The former variety occurs early in the 
disease, and is a thinning of the hair in irregularly shaped 
patches scattered over the scalp, giving to it an appear- 
ance similar to what would be produced by cutting the 
hair carelessly with a pair of dull shears. In rare cases 
we may have a general loss of hair from all hairy regions. 
The broken arch of the eye-brow is .always suggestive of 
syphilis. There may be some seborrheal dermatitis 
with this form of alopecia. Syphilitic macules may be 
on the scalp, but quite commonly there are none. 

Localized baldness is one of the later manifestations of 
syphilis, and is always preceded by a destructive disease 
of the scalp. The bald spots will vary in size with the 
extent of the destructive process, which may be one of 
absorption or ulceration. 

Diagnosis.— The diagnosis of early syphilitic alopecia 
is made by observing the irregular shape of the patches 



DEFLUVIUM CAPILLORUM 99 

and that they are not completely bald, and by the occur- 
rence of the broken arch of the eye-brow and the presence 
of other manifestations of the disease. These should 
arouse suspicion, and other symptoms of the disease 
may be found. It most resembles alopecia areata, but 
in that disease the patches are perfectly circular or oval 
and entirely bald. 

The baldness due to destructive forms of syphilis 
may be confounded with that of favus. In the latter 
disease the scalp preserves a reddish color for a long 
time, and then assumes an atrophic, smooth, cicatricial 
look, which is characteristic of it. The history of the two 
cases is very different, as in favus we do not have ulcer- 
ation, and we do have cupped, sulphur-yellow crusts. 
Favus is also more widespread and disseminated than is 
late syphilis of the scalp. 

Treatment. — The treatment of this form of baldness 
is that of the underlying disease. A mercurial ointment 
or a lotion containing bichloride of mercury may aid in 
hastening the new growth of the hair in the early form of 
baldness. The late form may be lessened by active 
constitutional and local treatment, according to the 
general principles laid down for the management of 
syphilis. 

Defluvium Capillorum is that sudden and general fall 
and manifest thinning of the hair which come on during 
or after some severe illness, such as parturition, fevers, 
mercurialism, and various cachexia? . 

Symptoms. — Rarely does it produce complete bald- 
ness. The fall is usually rapid and takes place during 
convalescence or after recovery, rather than during the 
course of the disease. It may not occur until from six 
weeks to three months after the illness. Seborrhea or 
pityriasis may or may not be present. Usually it is a 
general thinning of the hair and not a localized baldness. 
It rarely causes absolute baldness, and complete recovery 
is the'rule. 



100 DISEASES OF THE SKIN 

Etiology. — The cause of the hair fall is the profound 
disturbance of the nutrition of the body, in which the 
hair sympathizes. 

Treatment. — The treatment is rather to be addressed 
to the patient than to the hair. If we can succeed in 
building up the patient's strength, the hair will take care 
of itself. The scalp should not be shaved. Local treat- 
ment is the same as in alopecia pityrodes. 

Alopecia Follicularis is baldness due to some disease of 
the scalp that either destroys the hair follicles or impairs 
the proper performance of their function. A history of 
the causative disease may be obtained, or the disease 
itself will be present. Impetigo; long-continued sycosis; 
inflammatory diseases, such as erysipelas; parasitic dis- 
eases, such as favus and ringworm; and destructive new 
growths, such as syphilis and lupus, all may cause alopecia 
follicularis. 

The etiology, diagnosis, prognosis, and treatment of this 
form of baldness are the same as that of the disease that 
gives rise to it, for which we must refer to the proper 
sections. 

Alopecia Areata. — Synonyms: Area Celsi; Area occi- 
dental diffluens, seu serpens, seu tyria; Alopecia cir- 
cumscripta; Porrigo sue tinea decalvans; Vitiligo capi- 
tis; Ophiasis; Phyto-alopecia; (Fr.) Teigne pelade; 
Pelade; (Ger.) Die kerisfleckige Kahlheit; Circum- 
scribed baldness. 

This form of baldness usually begins suddenly, the 
patient discovering by accident, or being told by some- 
one, that he has a bald spot. Sometimes, on waking in 
the morning, the patient is astonished to find loose 
hairs in his bed, and, on looking in the glass, to see that 
he has a bald patch on his head. In some cases the hair 
fall may have been preceded for days or weeks by neu- 
ralgic pains in the head. In other cases the patient suffers 
from paresthesias of various kinds, such as formication, 
prickling, etc. In most people there are no premonitory 



ALOPECIA AREATA 



101 



symptoms and, apart from the bald spots, no discomfort 
on the part of the patient, nor cutaneous lesions. The 
neuralgia may continue after the hair fall or it may 
cease. There ma}' be but one bald patch or there may 
be a dozen patches. A patch may be as small as a three- 
cent silver piece or as large as a silver dollar. If larger — 
and the whole head may be completely bereft of hair — 
the patch is formed by the coalescence of several smaller 
ones. A patch may attain its full size at once or it may 
slowly enlarge, spreading at the periphery. The patches 

Fig. 10 




Alopecia areata. 



are more or less perfectly oval or circular in shape and 
sharply defined against the surrounding hair. Patches 
formed by the coalescence of other patches lose the oval 
outline and may have a scalloped border. The color 
is usually that of the normal scalp; it may be pale or 
hyperemic. The patch is perfectly bare and smooth, 
without scales, as a rule. Sometimes it is dotted over 
with short, broken hairs, old roots that soon fall out. 
Sometimes it looks as if it were depressed, an appearance 
due to falling out of the hair roots. Sometimes there is 



102 



DISEASES OF THE SKIN 



more or less seborrheal dermatitis of the scalp. Any or 
all the hairy regions of the body may be affected, the 
patient sometimes being entirely denuded of hair. The 
complete form we have met with three times in 120 
private cases. To it the term malignant alopecia areata 
has been applied. Most often it is the scalp that suffers, 
especially the temporal and occipital regions. The 
bearded portion of the face may be affected alone. Around 
the border of a recent patch the hair is loosened so that 
it may be readily extracted. They often present the 





Fig. 11 








n 




4*\ ; 





Alopecia areata. 



appearance of an exclamation point (!), because the 
shaft is thick while the bulb tapers off and ends in a 
small knob. When the patch is fully formed the hairs 
about it will be firmly seated in their follicles. The 
sensibility of the skin may be diminished. Generally 
it is preserved. 

The course of the disease is chronic, with a strong 
tendency to spontaneous recovery in anywhere from three 
months to several years. Recovery is heralded by the 

1 By the courtesy of Dr. S. Dana Hubbard. 



ALOPECIA AREATA 103 

growth of a fine down upon the bald patch. This will 
fall out and be replaced by lanugo hairs that in their 
turn will fall out to be replaced by stronger hairs, until 
normal hairs grow at last, though these at first may be 
white. Some cases relapse year after year. This occurs 
in from 20 to 30 per cent, of the cases. In some cases 
the hair never grows beyond the lanugo stage; and in 
other cases the patch remains permanently bald. 

Ophiasis is that form of the disease which begins over 
the nape of the neck, or by two lateral, symmetrical, 
occipital patches, and spreads forward as a broad band 
following the lower border of the hair and ending over 
the ears on the forehead. Starting in this way it may 
involve the whole scalp. 

Alopecia neurotica is that form of the disease in which 
the patches are irregular in shape in the form of stripes, 
triangles, or with map-like outlines shading off into the 
surrounding hair. 

Etiology.— The subjects of the disease may be in 
apparently perfect health, but not infrequently they 
are of very nervous temperament, exhausted by over- 
work or nervous strain, or out of health in some way. 
Both sexes are affected, the female rather more than 
the male in our experience, while Sabouraud's statistics 
show the reverse proportion. It occurs very often in 
children. The youngest case reported by Crocker was 
two years of age. Cases have been seen as late as 
in the sixtieth year. It is rather more frequent among 
the poor than among the well-to-do. It is more fre- 
quent in some countries than in others. Syphilis, either 
hereditary or acquired, has been found in connection with 
some cases. Sabouraud 1 has noted the disease in women 
to follow the menopause or prolonged suppression of 
menstruation, as in pregnancy. He has seen it in a man 
with double tubercular orchitis. 

The disputed points in the etiology of alopecia areata 

1 Annal. derm, et syph., 1913, iv, 88. 



104 DISEASES OF THE SKIN 

are its contagiousness, and whether it is a neurosis or a 
parasitic disease. At the present time it is impossible to 
decide with absolute certainty which of the contending 
parties is right. Most instances of contagion have been 
reported by French observers whose diagnostic skill we 
can hardly call in question. They have reported instances 
in which a large number of cases have appeared in bar- 
racks or schools, and from there spread to neighboring 
towns. In England similar apparent epidemics have 
been reported, but as a fungus indistinguishable from the 
trochophyton fungus was found in the surrounding hairs 
they were doubtless instances of bald ringworm. It is 
possible that some of the French epidemics were of 
similar character. In this country one epidemic appar- 
ently of alopecia areata has been reported by Putnam. 1 
The cases were examined by Drs. J. C. White and 
J. T. Bowen, of Boston, who agreed in the diagnosis. 
Nothing suggestive of trichophytosis was found. Isolated 
instances of apparent contagion have been reported by 
various physicians. We have met several times with 
more than one case in the same family or environment. 
Besnier and Doyon, 2 who believe firmly that the disease 
is contagious, think that it is transmitted most often 
by "means of the barber's utensils, especially the patent 
hair clippers, and that it is impossible in a great number 
of cases to trace the contagion. Hutchinson and some 
other English authorities are inclined to the belief that 
in many cases ringworm preceded the appearance of the 
bald spots at a greater or less interval. 

As to the parasitic origin of the hair fall, it is not yet 
proved. A goodly number of skilled microscopists have 
described a microorganism, but they do not agree among 
themselves. Still, it is assumed that a microorganism will 
be demonstrated at some time. 0. Lassar 3 thinks that 



1 Arch. Pediat., 1892, ix, 595. 

2 Path, et Traite des Mai. de la Peau: Kaposi. French edition, 
Paris, 1891. 

3 Dermat, Zeitschrift, 1900, vii 809. 



ALOPECIA AREATA 105 

the phenomenon can be best explained on the theory of 
a virus due to a microorganism. 

This leaves only the nourotic theory. Most derma- 
tologists believe the disease to be a trophoneurosis. It 
has been known to follow blows or injuries to the head, 
moral or mental shock, operations on the neck, and, 
experimentally, injury to or extirpation of the second 
cervical ganglion in cats. It has often been met with in 
association with various nervous diseases. Jacquet has 
asserted that carious teeth are in causal connection with 
many cases, and Whitfield would add eye-strain and 
severe infection with pediculi capitis. 

Perhaps the disease should be regarded rather as a 
symptom due to a disturbance of the nutrition of the 
hair depending sometimes on microbic infection, at other 
times on a trophoneurosis. For the present no decisive 
answer can be given to the question: "What is the 
cause?" 

Pathology. — Though hairs taken from the margin 
of an advancing area show trophic changes, there is 
nothing distinctive about such changes. A. R. Robinson 1 
found evidences of inflammation, and some round-celled 
infiltration confined principally to the perivascular region. 
In recent cases there was a coagulation of lymph in many 
lymphatics, and of fibrin in a few of the large and small 
arteries, with, in old cases, a thickening of their walls. 
In recent cases the hair follicles were either without 
hair or contained a lanugo hair or a hair just about to 
fall. The hair roots, where present, showed atrophic 
changes. In advanced cases the sebaceous glands were 
degenerated or had entirely disappeared. In the worst 
cases there was complete atrophy of the hair follicles 
and of the subcutaneous fatty tissue. He also describes 
the presence of various cocci in the lymph spaces of the 
corium and the walls of a few of the vessels, which he 
regards as the cause of the disease. 

1 Monatshefte f. prakt. Dermat., 1888, vii, 409. 



106 DISEASES OF THE SKIN 

Diagnosis.— A typical case of alopecia areata is so 
peculiar that there is little danger of mistaking it for 
anything else. It differs from trichophytosis capitis in 
its sudden onset, its perfectly bare, smooth, non-scaly 
surface, without broken, split, and gnawed-off hairs, 
and in the absence of the trichophyton fungus from the 
hair and scales taken from the neighboring parts. In 
bald ringworm patches, which resemble alopecia areata, 
the fungus will be found in the neighboring hair, or some 
characteristic " stumps" will be found on the scalp. In 
adults, ringworm of the scalp is very rare. It differs 
from favus in the absence of cupped crusts at any time 
in its course, in the scalp not presenting that cicatricial 
appearance always met with in favic baldness, and in 
complete absence of fungus growth. 

The baldness due to syphilis may resemble that of 
alopecia areata, but other symptoms of syphilis will be 
present, and there will never be a history of the for- 
mation of well-defined oval or circular areas. Lupus 
erythematosus at times affects the scalp and produces cir- 
cumscribed bald areas; but these are not oval or round, 
and the skin is red and scaly, and evidently cicatrized. 
Alopecia cicatrisata differs from alopecia areata in not 
forming regular oval or round bald areas, but rather 
irregular ones, with clumps of hair at their borders; in 
having a cicatricial appearance, and in presenting, at first 
at least, some evidences of dermatitis or folliculitis. When 
the inflammatory symptoms have subsided the diagnosis 
is sometimes difficult. Joseph has found that if the 
doubtful patch is painted with chrysarobin in traumaticin 
it will cause the mouths of the follicles to appear as brown 
or black dots if the case is one of alopecia areata, but not 
if it is alopecia cicatrisata. 

Treatment. — In a disease that is essentially self- 
limited it is hard to estimate how much good our reme- 
dies do. One duty we have without perad venture, and 
that is, to look after the general condition of the patient. 
A large number of the cases require a stimulating and 



ALOPECIA AREATA 107 

tonic treatment — iron, quinin, strychnin, arsenic, cod- 
liver oil, phosphorus or the hypophosphites. Children 
should be taken out of school and allowed to run free. 
Our hardest task will be to manage those nervous patients 
who are ever a trouble to us. The teeth and eyes should 
be examined and any defect corrected. 

As far as local treatment is concerned, it may be sum- 
med up in two words: patience and stimulation. As 
many of our parasiticides are stimulating to the skin, 
they may be used with benefit whether we believe in the 
parasitic cause of the disease or not. 

The stronger water of ammonia dabbed on the scalp 
several times a day by means of a swab, care being 
taken to guard the eyes, will be beneficial in some cases. 
It is remarkable how little reaction this powerful remedy 
will cause in alopecia areata. Pilocarpin, in hypodermic 
injections, or in ointment form, combined with sulphur 
ointment and well rubbed in, is at times beneficial. 
A good formula is: 

f£ — Pilocarpin. niuriat., gr. iv 26 

Sulphur, colloidal, 3J 4 

Adepislanae, 

Adepis anserini, aape. ad 5j 32 

01. rosa? geran., gtt.xv 

The scalp may be painted with acetic acid until it 
whitens, and then sponged off with cold water, and this 
repeated ever}' three or four days. Chrysarobin, 2 to 10 
per cent, in traumaticin, applied two or three times a 
week until inflammation is caused, is advised by Joseph. 
A mild ointment is used until the reaction subsides, when 
the chrysarobin is repeated. It may also be used in a 
saturated solution in chloroform and painted over with 
collodion when the solution dries. Hodara 1 exhibits 
it in a 25 per cent, mixture with ichthyol, and covers 
this with gauze. Care must always be taken that it 
does not get into the eyes. 

1 Monatshefte. f. prakt. Dermat., 1909, xlviii, 508. 



108 DISEASES OF THE SKIN 

Carbolic, acid (95 per cent.) applied every two weeks 
or so to small areas at a time ; bichloride of mercury, 2 to 
4 grains to the ounce in alcohol,, or oleum pini sylvestris; 
the oleate of mercury, in the strength of 2 to 10 per cent.; 
blistering with cantharides, or 33 per cent, of iodin in 
collodion, have one and all been followed by the return 
of the hair. 

Moty 1 reports good results from hypodermic injections 
of bichloride of mercury, injecting 5 or 6 drops of an 
aqueous solution (1 to 500) into many places about each 
patch. In a later number of the same journal he an- 
nounced that he then used a 4 per cent, solution of the 
mercury, with a 2 per cent, solution of cocain; that he 
made but a single-drop injection in a medium-sized patch, 
and four or five injections about a large patch, and at 
its periphery. Pauses of four days were taken between 
the injections, and a cure was expected after the fourth 
series. 

Sabouraud 2 advises in single-patch cases cutting the 
hair short, epilating about the patch, and rubbing the 
patch every second day with 1 part of Bidet's vesicating 
liquid and 3 or 4 parts of chloroform. Every morning 
the whole scalp is to be rubbed with: 

I£— Alcohol, camphorat., 5iv 128 j 

Spts. terebinthinae, 5y 20' 

Aquae ammonise, 3J 4 M. 

If the patch is very large, instead of the cantharidal 
solution use: 



-Ac. acetici crystal, gr. i-iij, .065-194 

Chloral., 3J 4 

iEther., 5J 32 



M. 



From time to time the patch should be shaved as the 
young hairs come in, w T hile the strength and the number 
of applications of the strong solution should be lessened. 
In obstinate cases he applies a blistering fluid at night to 

1 Ann. de derm, et de syph., 1891, ii, 406. 

2 Diagnostic et traitement de la pelade et des teignes de l'enfant. 
Paris, 1895. 



ALOPECIA AREATA 109 

a limited area, opens it the next morning and paints the 
surface with nitrate of silver solution. The surface is to 
be covered with absorbent cotton. This is to be repeated 
every week. 

Lactic acid in 50 per cent, aqueous solution is highly 
commended by Balzer. 1 Alcohol or ether is to be used 
first to remove the fat from the part, and then the acid is 
to be rubbed in with a tampon until the scalp reddens. 
Use daily. If reaction is too great, omit for a few days 
and use borated vaselin. A cure may be expected in 
from two to three months. 

Trikresol and alcohol, equal parts, is an excellent 
remedy. After a few days it may produce marked reaction, 
the scalp becoming red and swollen. When this occurs 
the reaction should be allowed to subside under cold 
cream. When it has subsided the trikresol should be 
again applied. It cannot be used in extensive cases, 
excepting in small areas at a time. 

Massage is useful. Good results have been obtained 
by actinotherapy. The Finsen apparatus or the iron 
electrode or Kromayer lamp may be used. The iron 
electrode lamp is to be held about three or four inches 
from the scalp. The time of exposure is from five to 
ten minutes, or until the scalp reddens. The exposures 
are to be repeated when the reaction subsides. Exposures 
to the Kromayer lamp are from about three to five 
minutes, repeated when the reaction subsides. Electricity, 
using the galvanic current, is well spoken of by some; 
and the high-frequency current is indicated. 

It is advisable to pluck the loose hairs from around 
the patch for a zone of perhaps an eighth or a quarter 
of an inch. Every few days slight traction is to be made 
on the hairs surrounding the patch and all the loose ones 
pulled. 

Prognosis. — Even if left to itself, the chances are that 
the hair will grow in again. This good prognosis should 

1 Monatshefte f. prakt. Dermat., 1900, xxx, 43. 



110 DISEASES OF THE SKIN 

be guarded when the patient is past middle life and in 
those malignant cases in which there is complete baldness 
that has lasted several years. In the latter when occur- 
ring in girls the hair may grow when menstruation is 
established. Relapses are frequent. 

Alopecie Innominee. — See Folliculitis decalvans. 

Anesthesia is a loss of sensation in the skin which 
occurs in a number of diseases of the nervous system, 
notably in hysterical affections. It may be general or 
partial, or affect but one-half of the body. There may 
be loss of sensibility to pain while the tactile sense is 
preserved (analgesia), or intense pain with loss of ordi- 
nary sensibility (anesthesia dolorosa). There are many 
substances which, locally applied, will cause anesthesia, 
such as carbolic acid, cocain, aconite; and many others 
which will abolish sensation when taken internally. The 
subject belongs to the domain of the neurologist. 

Anatomical Tubercle. — See Tuberculosis verrucosa cutis. 

Angiokeratoma 1 is the name given by Mibelli to a 
peculiar disease of the skin of the hands, feet, and ears 
that has been called telangiectatic warts, or vermes 
telangiectasiques. 

Symptoms. — Angiokeratoma follows chilblains or ex- 
posure to cold, and affects principally the dorsal aspects 
of the hands and feet, though their plantar surfaces may 
be involved to a slight degree, and the toes also. A few 
cases have occurred on the scrotum. The eruption con- 
sists in tiny, almost imperceptible, pink points that do 
not disappear on pressure; of pinpoint- to pinhead- 
sized darker spots that can be made almost to disappear 
on pressure, leaving a deep-red capillary loop in the 
centre; and of clustered telangiectatic points forming 
small irregularly shaped, slightly elevated groups. These 
groups may be as large as a split pea or bean; they may 

1 British Jour. Dermat., 1891, iii, 2.37. 



ANGIOKERATOMA 



111 



project for half a line above the surface, are hard, rough, 
warty looking, and of dull purplish-brown color. Pressure 
upon them brings out the telangiectatic character of the 
growths. When pricked with a needle free hemorrhage 
takes place. The eruption is symmetrical, as a rule, and 
usually affects more than one member of a family. It 

Fig. 12 




begins in early life usually, though it may occur later. 
It is more common in women than in men. There are 
no subjective symptoms. 

Pathology. — J. A. Fordyce 1 found in his case that 
the lesions were composed of lacunar spaces filled with 



1 Jour. Cutan. and Gen.-Urin. Dis., 1896, xiv, 81, 



112 DISEASES OF THE SKIN 

blood, occupying the papillary portion of the derma. 
He thinks that the vascular changes are primary. 

Tkeatment. — The treatment that proves most bene- 
ficial is destruction by electrolysis. The hands and 
feet should be warmly covered in winter time and the 
circulation improved. 

Angioma. — See Nevus vascularis. 

Angioma, Infective. — See Angioma serpiginosum. 

Angioma Pigmentosum et Atrophicum is the name pro- 
posed by R. W. Taylor for the xeroderma of Kaposi, and 
is described in this book under Atrophoderma pigmen- 
tosum, which see. 

Angioma Serpiginosum. — It has also been named in- 
fective angioma and nevus lupus. This is a rare disease, 
of which but few cases have been reported. White 2 de- 
scribes the disease as beginning as minute vascular papules 
that slowly increase to the size of a pea and then undergo 
spontaneous involution in the central portions, while 
they spread outward in an annular form to an indefinite 
extent and for an indefinite period. By the end of ten 
years the circinate patches may be no larger than one 
or two inches in diameter. The margin of the rings is 
elevated and of uniform breadth. New foci continually 
develop at a distance of one-eighth to one- third of an 
inch beyond the older areas. These, in turn, are con- 
verted into rings in the same way. The lesions are firm 
and smooth, and of bright-red to claret color. The 
centre of the rings is not elevated, and remains of a 
dull pinkish-brown tint. There are no subjective symp- 
toms. White's case was on the right shoulder. Other 
cases have been on the arm, cheeks, and legs. Sometimes 
nearly if not all the cutaneous surface of the body is 
involved. 

Most of the cases develop in early life. They may 
start from a vascular nevus. The pathology is undeter- 

1 Jour. Cutan. and Gen.-Urin. Dis., 1894, r xii, 505. 



ANGIOMA SERPIGINOSUM 



113 



mined. In White's case the growths were composed 
mostly of endothelial cells and the disease was thought 



Fig. 13 




Angioma serpiginosum 



to be of sarcomatous nature. Electrolysis or destruction 
by cauterization along the borders of the areas may be 



Sequeira, British Jour. Dermat., 1912, xxiv, 35; 



114 DISEASES OF THE SKIN 

used in the treatment of the disease, but the result of 
treatment is doubtful. 

Anhidrosis or Anidrosis. — By this is meant an affection 
of the sweat glandular apparatus attended by a diminu- 
tion or more or less complete suspension of its functions. 
It is a symptom rather than a disease. It may be local 
or general; temporary or permanent; symptomatic, as 
in fevers and diabetes; congenital, as in xeroderma; or 
neurotic. Some people never sweat perceptibly. In 
certain skin diseases, such as psoriasis, scleroderma, 
squamous eczema, and ichthyosis, the affected areas do 
not sweat. Its treatment is tonic by exercise and bath- 
ing. In symptomatic cases we must strive to remove 
the underlying cause. For congenital cases we can do 
nothing. 

Anonychia means congenital absence of the nail. 
Anthrax. —See Carbuncle and Pustula maligna. 
Aplasia Moniliformis. — See Trichorrhexis nodosa. 
Aplasia Pilorum Intermittens. — See Trechorrhexis nodosa. 
Area Celsi. — See Alopecia areata. 

Argyria is the blue or black discoloration of the skin 
and mucous membranes due to the deposition of particles 
of silver in the rete, sweat glands, and about the hair 
follicles, where it turns black by exposure to the sunlight. 
It used to be seen more often when silver salts were 
administered in the treatment of epilepsy than it is now. 
It occurs also in workers in metallic silver, minute par- 
ticles of the metal becoming fixed in the tissues. It has 
followed the use of nitrate of silver in laryngological 
treatment of other diseases. It is a permanent staining. 

Asteatosis or Xerosis. — This is an unnatural dryness of 
the skin, which is accompanied by desquamation and 
sometimes thickening, induration, and cracking. It is 
due either to an absolute or relative absence of fat 
and sweat glands, or to the action of substances that 
withdraw the fat from the skin, such as alkaline solutions. 



ATROPHIA PILORUM PROPRIA 115 

It is often seen in old age and in combination with other 
dermatoses, such as ichthyosis and dermatitis exfoliativa. 
The treatment of idiopathic cases is by the application 
of oily substances. In cases artificially produced the 
avoidance of the cause will cure the condition. 

Atheroma. — See Sebaceous cyst. 

Atrophia Pilorum Propria. — Atrophy of the hair exists 
under three forms, namely, Fragilitas crinium, Trichor- 
rhexis nodosa, and monilethrix. In all forms the hair 
shaft is easily friable and splits or breaks of itself or by 
the slightest traction. 

Fragilitas Crinium. — This disease has been called 
scissura pilorum, and has for its distinguishing feature 
splitting of the hair. It may be symptomatic or idio- 
pathic. The cleft is usually at the free extremity, and 
at times runs some distance up the shaft. The split 
hairs are either scattered here and there through the 
otherwise normal hair, or all the hairs of the part are 
split. The disease occurs most often upon the hair 
of the scalp, the beard being the place next most fre- 
quently affected. It is a common occurrence in the long 
hair of women. The shaft may be split into two or more 
fibrillar, and these spread out from each other simply, 
or curve up upon themselves. The cleft may also occur 
in the middle of the shaft or at its exit from the follicle, 
and in the latter case the shaft will be split throughout 
its entire length, the segments either separating or 
holding together. Duhring 1 reported a case occurring 
in the beard in which the hair began to split within the 
bulb. Besides the splitting, the hair may show no other 
abnormality, but it is generally more dry and brittle than 
normal, and may be irregular and uneven in its contour. 
The bulb of the hair may be normal or atrophied. 

Etiology. — The cause of the idiopathic fragilitas 
crinium is yet undetermined. The disease is, without 
doubt, due to some interference with the nutrition of the 

1 Amer. Jour. Med. Sci., July, 1878, p. 88. 



116 DISEASES OF THE SKIN 

hair, probably a yet undetermined trophoneurosis. The 
symptomatic form is also due to interference with the 
nutrition of the hair, but now there is often some evident 
disease of the scalp like seborrheal dermatitis; or to some 
trouble with the general nutrition of the body, such as 
gout or some cachexia. 

Treatment.— When occurring only at the free end of 
long hairs they should be cut above the cleft. In all 
cases the scalp should be kept in good condition, as 
directed under Alopecia prematura and the general con- 
dition of the patient improved. If the disease occur in 
the beard, shaving would at least remove the deformity 
and possibly cure the disease. 

Trichorrhexis Nodosa. — Synonyms: Trichoclasia ; Tri- 
choptylose ; Clastothrix. 

Symptoms. — The disease most often affects the hair 
of the beard and moustache, and here it reaches its 
highest development. It is found also on the hairs of the 
pubic region and on the scalp and axillary hair. Raymond 1 
says that he has found it on the labia majora in 60 per 
cent, of all women he has examined, and especially in fat 
women with intertrigo. He has found it also on scrotal 
hairs. It consists of one or more whitish or grayish, 
shiny, transparent nodular swellings occurring along the 
shaft of the hair. In people with red hair the color may 
be black. The number of nodes that may be present is 
from one to six, placed about one-half inch apart, and 
their size will vary with the diameter of the hair. The 
nodes, according to S. Kohn, 2 occur usually in the upper 
third of the hair. These nodes give to the hair an appear- 
ance not unlike that produced by the presence of the 
nits of pediculi. The hair is exceedingly brittle and 
fractures upon slight traction or spontaneously, the 
fracture taking place through a node and the hair fibers 
separating like the hairs of a brush. When many hairs 
in the beard are thus broken, their frayed-out ends make 

1 Ann. de derm, et de syph., 1891, ii, p. 568. 

2 Vierteljahr. f. Derm. u. Syph., 1881, viii. 581. 



ATROPHIA PILORUM PROPRIA 117 

the beard look as if it were singed. Sometimes the hair 
fibers splinter about the node, but the two ends do not 
separate, and this gives an appearance like as if two small 
paint brushes were pushed together. Sometimes the 
hair presents an irregular contour and looks as if frayed 
along its entire length. While the fracture is usually 
transverse, if there should be an excessive amount of 
medulla present in the node it may be longitudinal. 
The hairs themselves are usually firmly fixed in the 
follicles. 

Fig. 14 




N 

Trichorrhexis nodosa. (Michelson.) 

Etiology. — The cause of the disease may be a micro- 
organism, as they have been found in relation to the 
disease by Hodara, Essen, and others. Hodara 1 de- 
scribed a parasite in the hair that he named bacillus 
multiformis trichorrhexides. E. Spiegler 2 has succeeded 
in cultivating a bacillus and in reproducing the disease 
by inoculation with its culture. The parasitic theory 
of origin is not generally accepted. In many cases it 
seems to be purely due to lack of nutrition. It is by no 
means rare in the long scalp hair of women who are in 
poor general condition. Anderson 3 has reported a case 
of hereditary trichorrhexis nodosa, the disease in his 
patient being congenital or nearly so. 

By some it is regarded as purely mechanical, due to 
the patient's habit of handling the beard, the hair of 
which is abnormally dry and brittle. 

1 Monatshefte f. prakt. Dermat., 1894, iv, 173. 

2 Arch. f. Dermat. u. Syph., 1897, xli, 67. 

3 Lancet, 1883, ii, 140. 



118 DISEASES OF THE SKIN 

Pathology. — The microscopic examination of the 
affected hairs shows that in the early stage of develop- 
ment of the disease there are simply a spindle-formed 
thickening in the continuity of the shaft of the hair and 
a swelling of the medulla, while the cuticle is still intact. 
Later the cuticle becomes cleft, and the cleavage extends 
on all sides of the node until the brush-like appearance is 
produced by spreading of the separate fibers. At the same 
time with the cleaving of the cuticle the medulla under- 
goes degenerative changes and may disappear entirely. 
There is either no marked change in the appearance of 
the hair root or it is slightly atrophied. Air globules are 
only very occasionally found in or about the nodes. 

Treatment. — The treatment of the disease is very 
unsatisfactory. Continued shaving, followed by a satu- 
rated solution of boric acid, probably offers the best 
hope. All sorts of applications have been made to the 
affected parts, generally of a stimulating character, par- 
ticularly various forms of mercurials, but without cura- 
tive effect. Gamberini in his work on the hair recom- 
mends either bathing the part with a lotion composed as 
follows : 

1$ — Potass, subcarb, 3ij 8 

Alcohol, dil., ad giij ad 100 M. 

or inunctions of tannic acid or oil of cade. 
Schwimmer advises that an ointment of: 



-Zincioxid., . gr. vi.i 

Sulphur, loti, gr. xv 1 

Ung. simp., 5hss 10 



M 



be rubbed in in the morning and evening. 

Besnier finds it useful to pluck the diseased hairs and 
to apply to the newly formed hairs tincture of cantha- 
rides, pure or diluted. Sabouraud. advises using daily: 



-Hydrarg. bichlor., 


gr. iv 


25 


Ac. tartaric, 


gr. viij 


50 


Resorcin., 


gr. xv-xxx 


1-2 


Alcohol, 






Mther., 


aa § iss 


aa 50 



M 



ATROPHIA UNGUIUM 119 

A 2 per cent, solution or ointment of pyrogallol or 
a 3 per cent, carbolic acid ointment has been advised 
by others. 

Upon the theory that the disease is due to handling 
hair that is abnormally dry, Joseph forbids washing 
with soap and water, and advises the daily use of sweet 
almond oil, or castor oil with 20 per cent, of alcohol. 

Allied to trichorrhexis nodosa we have Monilethrix, 
also called aplasia pilorum intermittens, or nodose or 
beaded hair, in which the hair shaft is marked by alternate 
swellings and constrictions, the latter being colorless. 
The hairs are liable to fracture through the constricted 
portion, in this way differing from trichorrhexis nodosa. 
Occurring on the scalp it produces patches of hair broken 
off near the scalp. The disease has been met with on the 
legs. It is probably due to a trophoneurosis. Heredity is a 
prominent etiological factor. It usually begins in infancy. 
Keratosis pilaris is commonly present. It has been known 
to follow nervous shock. It begins in the hair follicle. Its 
cause is undetermined. Treatment is unavailing. 

Atrophia Unguium. — Atrophy of the nails occurs as a 
symptom of very many diseases of the skin, such as 
lichen ruber acuminatus, pityriasis rubra, psoriasis, and 
syphilis; or it may be caused by the invasion of the nail 
bed by parasites, as in favus and ringworm. It may 
also occur like defluvium capillorum as a sequence to 
some grave acute illness, such as typhoid fever or scar- 
latina, or some cachexia, such as diabetes. The nails 
may be congenitally absent or deficient, or become so 
without apparent cause. Injuries and certain chemicals 
will cause the nails to atrophy and fall. Atrophy is 
shown by white spots in the nails, leukopathia unguium, 
by loss of luster, by transverse white lines, by longitudinal 
or transverse furrows, by a worm-eaten appearance, 
or by a general thinning and breaking away of the nail- 
plate. In that form that is called spoon nail there is a 



120 



DISEASES OF THE SKIN 



central depression, a scooping out of the nail, the edges 
of which are everted. 

Treatment. — The treatment is most unsatisfactory. 
If the cause can be discovered and removed, the nail 
will recover. In many cases all we can do is to protect 
the nail by rubber cots or by the use of wax or other 
protective. Ointments of lead, zinc, or mercury may be 
rubbed in. The persistent use of sulphur ointment, 
combined with the administration of arsenic, will prove 
beneficial in those cases apparently dependent upon nerve 
disturbance. 

Atrophoderma or Atrophia Cutis. — Atrophy of the skin 
may be quantitative or qualitative; idiopathic or symp- 
tomatic; diffused or circumscribed. Crocker 1 gives this 
useful table: 



D iff u sum 



[Juvenilis 



/Pigmentosum. 



Atrophoderma 
Idiopathicum 



~S Congenitalis \Albidum 
sSenilis 



Circumscriptum 
v (striae et maculae) 



Atrophoderma 

Symptomaticum \ 



f Neuriticum 
(glossy skin) 



Morborum cutis 



fQuantitativum. 
(Qualitativum. 
/Traumaticum. 
\Non-traumaticum. 

j Traumaticum . 

1 Non-traumaticum. 

( Scleroderma. 

Seborrhea. 

Lupus. 
I Syphilis. 
(Favus, etc. 



The symptomatic atrophies will be spoken of under 
their proper headings. The other forms of atrophy will 
be considered here. 

Atrophoderma Pigmentosum. — Synonyms : Xeroderma 
pigmentosum (Kaposi); Angioma pigmentosum et atro- 
phicum (Taylor); Dermatosis Kaposi (Vidal); Liodermia 
essentialis cum melanosi et telangiectasia (Neisser); 
Melanosis lenticularis progressiva (Pick) ; Lentigo maligna 
(Piffard); Epitheliomatose pigmentaire (Besnier). 

This is a very rare disease of the skin, first described 
by Kaposi in 1870 under the name of xeroderma, to which 



1 Diseases of the Skin, London and Philadelphia, 1905. 



A TROPHODERMA PIGMENTOS UM 



121 



he subsequently added the adjective pigmentosum. It 
is a congenital disease; almost all cases begin before the 
second year of life. 

Symptoms. — It affects the parts most exposed to the 
air: the face, neck, chest, and back down to the level of 
the clavicles, or even the third rib, the backs of the 
hands, forearms, and upper arms. The hands, face, and 
neck are most markedly diseased, while a few cases have 

Fig. 15 




Atrophoderma pigmentosum. (After Crocker.) 

occurred upon the scalp, legs, and back of the feet. 
It begins with erythematous patches, like those produced 
by sunburn. After a time brown or black freckle-like 
spots form upon the erythematous ones. They are from 
pinhead to bean size, and round or irregularly shaped. 
Small red spots appear among the pigmented lesions, 
which Taylor thought were their forerunners. This 
is denied by other observers. The pigmented spots 



122 DISEASES OF THE SKIN 

in time give place to white atrophic ones, and the skin 
becomes too small for the underlying parts, so that it 
appears drawn and in some places bound down. A 
fully developed case presents a vast number of lentigi- 
nous spots interspersed with white atrophic spots and 
stellate and striate telangiectases. After a time, on 
account of the atrophy of the skin, we find ectropion, 
thinned alse nasi, and contracted nasal and oral orifices. 
There may be white atrophic spots on the mucous mem- 
brane of the lips. Conjunctivitis generally supervenes 
upon the ectropion, and the discharge from the eyes sets 
up ulcerations which in their turn give rise to other 
ulcerations. Warty growths at last appear, and these 
are prone to take on malignant action and be converted 
into epitheliomas, the patient dying at an early age 
from marasmus, although in some cases the course of 
the disease is prolonged for ten, twenty, or thirty years. 
At first, however, there is no disturbance of the health. 

Etiology. — The etiology of the disease is obscure. 
It is supposed by some to have its starting-point in irrita- 
tion of the skin by the sun or other irritant. Many of 
the cases begin in the summer. It is supposed by others 
to be a trophoneurosis. It is found in both sexes, and 
is peculiar in affecting several members of the same 
family and of the same sex, and in beginning in the first 
or second year of life. It may be hereditary. In a few 
of the cases there was a history of cancer in the family. 
Thus far microscopic investigations have failed to throw 
light on the pathology of the disease. 

Diagnosis. — The disease is to be differentiated from 
scleroderma by the peculiarity of its being limited to 
exposed parts, by lacking stony hardness, by occurring 
early in life, and by the general picture of pigmented 
and atrophic spots and telangiectases being intermingled. 
It differs from urticaria pigmentosa in not itching, in not 
occurring upon the trunk, in the absence of wheals, and 
in the presence of telangiectases and warty or epithelio- 
matous growths. 



ATROPHODERMA IDIOPATHICA DIFFUSA 123 

Treatment. — Nothing has yet been found to stop the 
progress of the disease. The conjunctivitis is to be cared 
for, the ulcerations on the face healed as rapidly as pos- 
sible, and the warty growths and epitheliomatous nodules 
destroyed at an early date so as to prevent the develop- 
ment qf epitheliomatous or carcinomatous ulcers. A 
saturated solution of boric acid will do much for the eyes; 
the ulcers may be treated with iodoform or aristol powder 
or a dilute ammoniate of mercury ointment; while the 
warty growths should be scraped off with a curette, and 
touched with acid nitrate of mercury. The axray may 
be used as in epithelioma for the healing of the ulcers. 

Prognosis. — The disease is fatal, death from marasmus 
taking place in from ten to twenty years. 

Atrophoderma Albidum is the name used by Crocker for 
a second form of the xeroderma pigmentosum of Kaposi, 
which is described by the latter as beginning in child- 
hood, affecting, most frequently, the lower extremities and 
less often the forearms and hands, and characterized by 
thinness of the skin, which in some places is stretched and 
cannot readily be taken up into folds. The color of the 
skin is pale and white, with a delicate rosy shimmer in 
places, and here and there its epidermis peels off in asbes- 
tos-like lamella. The treatment is simply protective. 

Atrophoderma Idiopathica Diffusa. — Synonyms: Atrophia 
maculosa cutis; Acrodermatitis chronica atrophicans. 
Diffused idiopathic atrophy of the skin is a very rare 
affection. It may be congenital or acquired, general 
or partial. The subcutaneous tissue disappears, so that 
the skin lies close to the underlying parts. It is thin, 
pale, stretched or wrinkled, easily movable over under- 
lying parts, and allows the bloodvesesls to show through. 
In some cases thick, scaly plates form, while in others 
these are wanting and there is only slight scaling. The 
elasticity of the skin is lost, so that if it is pinched up 
into folds these slowly flatten out. In some cases the 
skin seems too small for the body, which, on the face, 



124 DISEASES OF THE SKIN 

gives rise to ectropion and other deformities. The 
sensibility of the skin may not be diminished. The 
patients are susceptible to cold. Ulcers are prone to form 
upon slight injuries. The hair is destroyed. The disease 
is probably a trophoneurosis. By some observers it is 
thought that a faintly marked inflammatory process may 
be the starting-point of the disease. One case was ascribed 
to exposure to cold. 1 Nothing can be done for these 
cases beyond oiling of the skin if any discomfort is felt. 

Hardaway 2 reported two cases occurring in a brother 
and sister; and Ohmann-Dumesnil 3 has met with a case 
of atrophy of the skin and muscles of the right arm 
apparently following an injury to the radial nerve by 
means of a burn on the hand. 

One variety of diffused idiopathic atrophy of the skin 
is that called hemiatrophia facialis progressiva, in which 
only one-half of the face is affected and the skin becomes 
thinned and shrunken so that it lies close to the bones. 

Under this heading may also be placed the glossy skin 
or atrophoderma neuriticum of Paget, Weir Mitchell, and 
others. It commonly affects the fingers, less often the 
extremities, and follows upon disease or injury of nerves. 
It occurs also in scleroderma. The fingers become dry, 
red, or mottled, look glazed or as if varnished, and are 
shrunken. The natural lines of the skin disappear and 
the nails fall off. If parts covered with hair are affected, 
the hair falls. Its tendency is to spontaneous recovery. 

Atrophoderma Senilis is a true atrophy of the skin that 
takes place in consequence of advancing years. Other 
degenerative changes also are present, as a rule. It may 
be partial or general. The skin looks wrinkled; it is 
thrown into folds, is dry and sometimes scaly, and is 
often of darker color than normal. By pinching up the 
skin the thinness of it is readily appreciated. With the 
atrophy of the skin there are likewise loss of the subcu- 

1 Pospelow: Ann. de derm, et de syph., 1886, vii, 505. 

2 Trans. Amer. Dermat. Assoc, 1884. 

3 Alienist and Neurologist, July, 1890. 



ATROPHODERMA STRIATUM ET MACULATUM 125 

taneous fat, pruritus, and verruca senilis. Treatment is 
out of the question, beyond oiling of the skin to make 
the patient more comfortable. 

Atrophoderma Striatum et Maculatum. — By this is meant 
circumscribed atrophic streaks or spots. They may be 
idiopathic or symptomatic. The idiopathic form is far 
more rare than the symptomatic form. 

Symptoms. — The idiopathic streaks are met with most 
often about the thighs, buttocks, and lower anterior part 
of the abdomen. They are one or two lines wide, slightly 
curved, and from one to several inches long. There are 
usually several present, and then the}' are arranged parallel 
to one another and run in an oblique direction. The 
macules are isolated, from pinhead to finger-nail size or 
larger, occur most frequently on the extremities and lower 
part of the trunk, but may occur as high up as the neck, 
and are less common than the streaks. Both forms of 
lesion are depressed below the surface of the skin, and are 
of a pearly or bluish-white color and have a glistening, 
scar-like appearance. They are not primary atrophies, 
but succeed to an erythematous hypertrophic lesion, in 
this greatly resembling morphea. They give rise to no 
inconvenience, and are accidentally discovered. They 
usually are permanent, though they may become less 
pronounced in time. 

Etiology.— The etiology is abscure. By many it is 
regarded as a trophoneurosis. Shepherd 1 and Duck- 
worth 2 have reported cases of atrophic spots and lines 
following fevers. 

Symptomatic lines and macules are very common, and 
are caused by the stretching or rupture of the more super- 
ficial bundles of white and elastic fibrous tissues of the 
skin. If the fibers are ruptured, the striae will be most 
pronounced, and there will be little left of the skin but 
the epidermis and a thin fibrous membrane. 3 This form 

1 Trans. Amer Dermat. Assoc, 1890. p. 23. 

2 British Jour. Dermat., 1893, v, p. 357. 

3 Taylor, R. W.: New York Med. Jour., 1886, xliii, p.l. 



126 DISEASES OF THE SKIN 

of atrophy of the skin is seen upon the abdomen of 
pregnant women (lineoe albicantes) and on the breasts of 
nursing women. It has also occurred about the joints in 
young people who have grown rapidly after being con- 
fined in bed with an illness such as typhoid fever. Atrophic 
lines are not infrequently seen on the upper part of the 
thighs, both in men and women. In fact, anything 
that greatly distends the skin may give rise to them, 
such as abdominal ascites, obesity, ovarian or other 
tumors. 

Treatment. — The treatment of these cases is purely 
expectant. Both the idiopathic and the symptomatic 
atrophies may grow less pronounced in time. 

Autographism. — See Urticaria factitia. 

Baelz's Disease of the lip is a chronic affection of the 
mucous glands of the lip marked by an indolent swelling 
and infiltration of the periglandular tissue, and a slow 
ulceration from above downward. It ceases only with 
the destruction of the affected gland. The neighboring 
lymphatic glands are not implicated. A superficial 
catarrhal inflammation of the mucous membrane of the 
lips frequently accompanies the process. There is no 
general systemic disturbance. It has no relation either 
to syphilis, tuberculosis, or cancer. It is regarded as a 
local infection. It is readily cured by the application 
of tincture of iodin, which at first is used every other 
day, and later every day. 

Baker's Itch. — See Eczema. 
Barbadoes Leg. — See Elephantiasis. 
Barber's Itch. — See Trichophytosis barbae. 
Bazin's Disease. — See Erythema induratum. 

Beigel's Disease is a parasitic growth found on false hair, 
marked by the appearance of dirty-brown nodes on the 
hair shaft. It is caused by a fungus of yet undetermined 
species. 

Birth-mark. — See Nevus. 



BOTRYOMYCOSIS HOMINIS 127 

Biskra Bouton or Biskrabeule. — See Aleppo boil. 

Black Tongue, Hairy Tongue, or Hyperkeratosis Linguae. 
— According to Stelwagon 1 this disease is most often 
located on the dorsum of the tongue, in front of the 
circum vallate papillae, but may occur elsewhere. The 
color is usually black, but may be yellow or blue. There 
may be simply discoloration, but more usually fine hair- 
like projections spring from the darkened patch. The 
disease may develop rapidly or slowly to areas of vary- 
ing size. After lasting for weeks, or years, it usually 
disappears of itself. It gives rise to no subjective symp- 
toms as a rule, excepting a mawkish taste, and rarely 
slight pain. 

The cause of the disease is unknown. It occurs both 
in children and adults, and in both sexes. Attention to 
the hygiene of the mouth and the use of an antiseptic 
mouth wash are the means for treatment. 

Blastomycetic Dermatitis. — See Dermatitis blastomy- 
cotica. 

Boil. — See Furunculus. 

Botryomycosis Hominis. — This is probably only "proud 
flesh" and due to staphylococcus aureus; though by some 
it has been thought to be caused by botryomyces. It is 
characterized by pedunculated rounded pea- to nut-sized 
red tumors with a more or less mammillated surface. 
They are soft and elastic to the touch, and sometimes 
bleed easily. Usually there is only one lesion. They are 
most often seen on the hands, but may occur anywhere. 
They usually start from a sligthly injured surface which 
has suppurated. They consist of a connective-tissue 
stroma and granulation tissue rich in bloodvessels. The 
epidermis over them is wanting either wholly or in part. 
They should be tied or cut off, and dressed with anti- 
septics, or curetted and the base cauterized. A better 

1 Diseases of the Skin, Philadelphia, 1914. 



128 DISEASES OF THE SKIN 

name for them is that proposed by Crocker, granuloma 
pyogenicum. 

Bricklayer's Itch. — See Eczema. 

Bromidrosis. — Synonym: Osmidrosis. This word means 
stinking sweat, which, though not elegant, is expressive. 
It most often affects the feet, and then is associated with 
hyperidrosis. It may be general, as in the negro race. 
The odor is not necessarily repulsive, a few cases having 
been reported in which it was that of violets. The 
axilla? are, next to the feet, the most common site of the 
trouble. The odors of different fevers and cachexia are 
usually classed under this heading, although they do not 
properly belong here. 

Strictly speaking, bromidrosis should include only 
those rare cases in which the sweat, when secreted, has a 
distinctive odor. Usually the odor in bromidrosis is not 
in the sweat, but in the products of decomposition, the 
fatty acids and the like. When the feet are the parts 
affected they will be found to be of a pinkish color about 
the soles and between the toes, or the skin will look 
sodden and grayish. When the hyperidrosis is well 
marked, and it commonly is, the feet may be so tender 
as to interfere with locomotion. The stench from a 
pronounced case is such that it is almost impossible to 
stay near the subject of the disease. 

Etiology. — The cause of general bromidrosis is either 
inherent in the race or unknown. Most of the cases, 
apart from the racial ones, have been in hysterical sub- 
jects. The taking of some drugs imparts their odor to 
the sweat. Asafetida, onions, musk, and other drugs 
may do this. In the usual form of the disease it is due 
to decomposition of the sweat in the stockings, shoes, or 
clothing of the individual. When the part is uncovered 
and kept clean, there is no odor. Thin described a 
parasite, that he named bacterium fetidum, as the 
cause of the disease. It is supposed that this bacterium 
can live only in an alkaline medium. The sweat is acid, 



BULPISS 129 

and, therefore, on most feet it does not grow, but when 
hyperidrosis macerates the epidermis and allows of the 
escape of serum the acidity of the sweat is neutralized 
and the bacterium flourishes. 

Treatment. — The treatment of the general cases is of 
no effect. In the local cases the hyperidrosis is to be 
overcome, as will be described in its proper place. The 
special treatment directed to the cure of the odor of the 
feet is to wash them with soap and water two or three 
times a day, to put on a clean pair of stockings every 
morning, to ventilate the shoes thoroughly, and to dust 
the feet, between the toes, the stockings, and the inside 
of the shoes with finely powdered boric acid. Thin 
recommends the wearing of cork inside soles, which are 
to be soaked in a saturated solution of boric acid and 
dried before using. Another useful powder is: 

R — Ac. salicylici, i 

Pulv. alum, exsic. vel. 3 iss-ii j 6-9 

Pulv. lycopodii, ad giij ad 120 | M. 

to be applied in the same way, twice a day. This will 
cause the skin to exfoliate, when the treatment may be 
stopped. 

W. Osier 1 reports one case of general bromidrosis cured 
by the administration of alkalies. 

Bulpiss 2 is a disease that occurs in Nicaragua, affecting 
every tribe, both sexes, and all ages, though rare in early 
infancy. It begins on the feet and hands, and spreads 
gradually; or upon the knees, or abdomen, or neck and 
face. Two kinds are described. In the white bulpiss 
there are crops of minute reddish papules, which on 
disappearing leave discolored spots. After a time the 
pigmentation fades away and leaves a dirty white, round 
or oval patch, with slightly elevated and partly dis- 
colored broad margins. In black bulpiss the patches are 
grayish black, and the skin is dry and shrivelled. Both 

1 Montreal Med. Jour., 1896-9, xxv, 890. 

2 O. Lerch: New Orleans Med. and Surg. Jour., 1894-5, xxii, 793. 

9 



130 DISEASES OF THE SKIN 

kinds jtch at night. It is contagious and probably para- 
sitic. It resembles if it is not identical with caraate. 

Bunion.— According to P. Syms, 1 a bunion is always 
secondary to an outward displacement of the first pha- 
lanx of the great toe, due to ill-fitting shoes. As a result 
we have a periostitis with hyperplasia, and finally exos- 
tosis of the metatarsal bones. The pressure between the 
exostosis and the shoe gives rise to an inflamed bursa, 
the bunion. Surgical interference and properly con- 
structed shoes are the only remedies. 

Cacotrophia Folliculorum. — See Keratosis pilaris. 
Calculi, Cutaneous. — See Milium. 

Callositas. — Synonyms: Callosity; Callus; Tylosis; 
Tyloma; Keratoma; (Fr.) Durillon. This is familiar to 
all as the callous skin of the hands met with in oarsmen, 
blacksmiths, and in those who follow other manual occu- 
pations, and is a hypertrophy of the epidermis consequent 
upon intermittent pressure of the skin against the under- 
lying bone. Constant pressure will cause atrophy. The 
same thickening of the skin is found upon the soles also, 
due to going barefoot or wearing improperly fitting shoes. 
This form of the disease is not infrequently met with in 
people who are past middle life, and sometimes is due to 
a flattening of the arch of the foot. In fact, it may 
develop anywhere under proper conditions. 

Treatment.— Cessation from using the hands will be 
followed in course of time by the disappearance of the 
callus. To hasten its removal we may use maceration 
with rubber cloth, continuously applied to the part, or 
soaking in hot water containing § to 1 ounce of carbonate 
or bicarbonate of soda to the gallon. Or a plaster of 
salicylic acid, or a solution of salicylic acid, 10 to 20 per 
cent., in ether or collodion. The action of these remedies 
will be aided by previously paring down the part with a 
sharp knife. When the soles of the feet are affected 

1 New York Med. Jour., 1897, Ixvi, 448. 



CANITIES 131 

special attention must be given to the shoes, and to 
rectifying any flat-foot by mechanical means. Salicylic 
acid and the daily soaking of the feet are the best local 
applications. 

Callus. — See Callositas. 

Calvities. — See Alopecia. 

tlancer. — See Carcinoma and Epithelioma. 

Canities. — Synonyms: Trichonosis cana; Trichonosis 
discolor; Poliothrix; Poliosis; Trichonosis poliosis; Spi- 
losis poliosis; Poliotes; Grayness of the hair; Whiteness 
of the hair; Blanching of the hair; Atrophy of the hair 
pigment. 

Grayness or whiteness of the hair may be congenital or 
acquired; the latter is by far the most common. The 
whiteness is either partial or complete. 

Congenital canities usually occurs in the form of tufts, 
sometimes in round patches, the more or less pure white 
hair showing conspicuously among the normal-colored 
mass. When the whiteness is general we have albinism, 
which is associated with a deficiency of pigment in the 
whole body. Cases of congenital canities are rare. 

Acquired canities may be premature or senile. Most 
often grayness does not begin before the thirty-fifth or 
fortieth year. If it occurs before this age, it may be con- 
sidered as premature; and when after this age as senile. 
Premature canities is by no means uncommon, many 
persons becoming gray between the twentieth and 
twenty-fifth year. The hair which first whitens is, as a 
rule, that of the temples; then follows, with more or less 
rapidity, that of the vertex and whole head. Some- 
times the beard first turns gray, but usually it changes 
color after the hair of the scalp. The last hair to become 
gray is that of the axilla and pubis. When the gray- 
ing is due to some passing cause, as anxiety or some 
diseased state, the process may cease completely upon 
removal of the cause. Usually the whiteness is progres- 



132 DISEASES OF THE SKIN 

sive and permanent. As a rule, there is no change in 
the color of the scalp, although in some cases gray tufts 
are found upon pale-yellow patches of the scalp. As in 
alopecia, so in canities, men are more frequently affected 
than women. 

The hair in canities is usually unchanged except in 
color, but it may be drier and stiffer than normal. Cani- 
ties may exist for years without alopecia. 

The hair turns gray first at its root. The color at first 
is gray on account of the mixture of the normal color 
with the whiteness due to the absence of pigment. 
Gradually the white parts gain the ascendant, and the 
whole hair is blanched, becoming finally of a yellowish or 
snowy whiteness. The darker the hair is originally the 
more it is prone to turn gray. 

Sudden change of color of the hair from its normal 
hue to perfect white has been two well authenticated to 
allow of a doubt as to its occurrence, though it has been 
denied by good authorities, who have questioned the 
correctness of the observations reported. 

Ringed hair is an anomalous variety of blanching of 
the hair in which the affected hairs are marked by alter- 
nate rings, one being that of the normal color, and the 
next white. The occurrence of this disease is very rare, 
and but few cases have been reported. 

The hair has been known to lose its color under vary- 
ing circumstances. Very commonly the first hair that 
comes in after alopecia areata is white. Wallenburg 1 
reports a case in which, after an attack of scarlatina, the 
patient's brown hair was entirely lost and replaced by a 
growth of white hair. Prolonged residence in a cold 
climate, with much exposure, will cause the hair to turn 
gray. Sometimes the hair will change its color with the 
season, becoming gray in winter and darker in summer. 
On the other hand, Cottle 2 gives prolonged residence in 
hot climates, with much exposure, as a cause of canities. 

1 Vierteljahr. f. Derm. u. Syph., 1876, iii, 63. 

2 The Hair in Health and Disease, London, 1877. 



CANITIES 133 

Albinos, we know, are most frequent in the negro races, 
which inhabit the hot countries. 

Etiology and Pathology. — Senile canities and many 
cases of the premature form are due to an obscure 
change in the nutrition of the hair papillee which inter- 
feres with the production of pigment. Only this func- 
tion of the papilla seems to be interfered with, as the 
hair-forming function is in full activity, judging from 
the fact that the hair in many cases is in full vigor. 
Metchnikoff 1 says that the loss of pigment is due to the 
phagocytic action of certain cells that he named pigmento- 
phages. These are cells of the medulla that become 
mobile, penetrate the cortex, absorb the pigment granules, 
and descend with the pigment into the bottom of the 
follicle and the adjacent connective tissue. In cases of 
sudden blanching of the hair the change of color is depen- 
dent upon the formation of air bubbles between the hair 
cells of the cortical substance, the presence of the air 
rendering the cortical substance opaque, so that the 
color of the pigment is obscured. There are various 
agents which act as active or exciting causes of canities. 
Age is one of the most prominent of these. Heredity 
exerts marked influence upon the blanching of the hair, 
most of the members of certain families turning gray 
at an early period of life. Neuralgia of the fifth nerve, 
dyspepsia of various forms, sudden fear or nervous shock 
(producing sudden blanching of the hair), profuse and 
frequent hemorrhage, excesses of all kinds, chronic 
debilitating diseases (as syphilis, malaria, and phthisis), 
local diseases or injuries to the scalp, as wounds, favus, 
repeated epilation, prolonged shaving, and the like, have 
been given by various writers as causes of canities. 
Schwi,mmer regards it as being principally a tropho- 
neurosis, and finds in the occurrence of grayness in the 
course of neuralgia a strong argument for his theory. 

Treatment. — We cannot restore the color to gray 
hairs. In some cases of canities occurring in the course 

1 Annal. de l'lnstitut Pasteur, 1901, p. 865. 



134 DISEASES OF THE SKIN 

of neuralgias, if we can cure the neuralgia, the color will 
gradually return to the hair. 

Besnier and Doyon suggest the use of acetic acid as a 
promotor of pigmentation, as they have seen numerous 
instances of its use in alopecia areata followed by growth 
of hyperpigmented hair. Pilocarpin applied locally in 
ointment or lotion, 3 or 4 grains to the ounce, may 
cause white hair to darken. 

All that can be done for canities is to restore artifi- 
cially the color by means of hair dyes, and their use is 
to be deprecated. Happily the custom of dyeing the hair 
is falling out of fashion. 

Carbuncle. — Synonyms: Anthrax, 1 Carbunculus; (Ger.) 
Brandschwar, Kohlenbeule. 

A phlegmonous inflammation of the skin and subcu- 
taneous tissue, attended with sloughing. 

Symptoms. — This disease begins as an innocent-looking 
papule, which, however, is far more painful, both sub- 
jectively and objectively, than an ordinary papule 
would be. Within twenty-four hours it becomes larger, 
more painful, slightly raised and reddened, and is gen- 
erally accompanied by a good deal of constitutional dis- 
turbance, such as chills, fever, and nervous irritation. 
All the symptoms increase in severity, the inflammation 
extends laterally and vertically, the swelling becomes 
darker in color, the pain more intense, throbbing and 
lancinating, and the constitutional disturbance may be 
so severe that the patient is compelled to go to bed. 
Within ten days, or perhaps longer, the swelling has 
reached its height. It may be two or three inches or 
more in width, with a brawny base that is more or less 
sharply defined, of irregular shape, firm to the touch, 
and with a wide area of edematous skin about it. Now 
it begins to soften, not like a boil with a central point, 
but with the formation of a number of small pea-sized 

1 Anthrax, a term that is often applied to carbuncle, should be used 
rather for malignant pustule or the local manifestation of splenic 
fever. 



CARBUNCLE 135 

purulent points, through which sanious pus exudes, giving 
to the surface a cribriform appearance. Sloughing takes 
place through the openings, that gradually enlarge, so that 
at last there results an irregular, deep, excavated ulcer 
with firm, sharply cut, everted edges. In very bad cases 
the whole mass may fall out at once. The ulcer gradually 
fills up, heals, and leaves a scar. With the discharge 
of the slough the patient gradually recovers his health; 
but in some cases, especially in persons already debili- 
tated or in elderly people, the disease runs a fatal course, 
the patient dying of exhaustion or pyemia, or the disease 
runs into a typhoid condition preceding death. Death 
may also result from acute sepsis, or from thrombosis 
or embolus, especially in carbuncles on the scalp. In some 
cases the resulting ulceration is very large, with a corre- 
sponding amount of general disturbance of the system. 
Dry gangrene may take place. 

The disease is rare in children, and most common in 
middle and old age. Men suffer more often than women. 
The most frequent locations of the disease are the upper 
dorsal region, back, buttocks, and forearms, although it 
may occur anywhere. It is usually a single lesion. The 
duration of the whole process is six weeks or more. 

Etiology. — The causes of the disease are very much 
the same as those of boils. While carbuncle is most apt 
to occur in those who are not in good health, it does 
occur at times in apparently robust subjects. Diabetics 
are frequent subjects; gout and uremia have been con- 
sidered as predisposing causes. The frequent location 
of the disease about the shoulders and on the back of 
the neck suggests pressure as a determining cause. 
Microorganisms are the exciting cause of the disease, 
the staphylococcus pyogenes aureus, albus, or citreus, being 
constantly found in the tissues of a carbuncle, especially 
the first. 

Pathology. — To Warren, 1 of Boston, we owe one of 
the most thorough studies of the pathology of carbuncle. 

1 Boston Med. and Surg. Jour., 1881, civ, 5. 



136 DISEASES OF THE SKIN 

He declares it to be a spreading phlegmonous inflamma- 
tion of the subcutaneous cellular tissue. The inflam- 
matory cells cluster in and about the columnar adiposse 
and push out laterally from them, infiltrating the skin. 
They reach the surface by mounting up along the hair 
follicles and arrectores pilorum muscles. The inflamma- 
tion starts from a skin follicle, or sebaceous gland; ex- 
ceptionally from deep down in the subcutaneous tissues. 

Diagnosis. — Carbuncle differs from furuncle in being 
single; in its brawny base; in its greater painfulness and 
constitutional disturbance; in its flatter shape and larger 
size, and especially in its opening at many points and 
presenting a cribriform surface rather than a central 
core and a crater-shaped opening. Its circumscribed 
shape, its lancinating pain, and its multiple sieve-like 
openings distinguish it from diffuse phlegmonous inflam- 
mation of the skin. Anthrax becomes gangrenous earlier 
than carbuncle and its centre sinks in instead of becoming 
elevated. 

Treatment. — As the disease is an exhausting one the 
patient's strength is to be supported from the start and 
his nutrition kept up by a generous diet. Fresh air by 
good ventilation must be secured. If the pain is excessive, 
opium or morphin is indicated, especially to procure 
sleep. Iron is a valuable remedy all the way through, 
and antipyretics should be administered if the fever is 
high. Alcohol should be given if suppuration is free, 
especially if there are any signs of exhaustion. 

The best local treatment in mild cases is the use of 
carbolic acid, and this gives such good results as to leave 
little to be desired. The crucial incision formerly prac- 
tised is now considered by many modern authorities as 
harmful, though it certainly gives relief for the time by 
removing tension. In like manner the old-time method 
of poulticing is condemned, though it, too, contributes 
to the comfort of the sufferer. If the comfort of heat 
is desired it may be obtained by hot fomentations with 
a boric acid solution. For ordinary carbuncles the most 



CARCINOMA 137 

efficient treatment is to inject them at several points 
with a 5 to 10 per cent, solution of carbolic acid in olive 
oil or glycerin, by means of an ordinary hypodermic 
syringe. When there are already sloughing points it is 
well to push into each of them a little absorbent cotton 
wound on the end of a wooden toothpick and dipped 
in carbolic acid, either pure or in 1 to 4 solution. These 
procedures are painful for a moment, but the pain soon 
ceases. Hyde and [Montgomery suggest the application 
of cupping glasses to draw out the pus after the carbuncles 
are open. The mass must then be covered with lint 
soaked in a weak solution of carbolic acid or in a saturated 
boric acid solution used hot. It is possible to abort some 
carbuncles by touching them with pure carbolic acid. 
E. O. Ashe 1 reports the cure of one case by the injection 
of antistreptococcic serum. Eade 2 says that it is possible 
to abort cases in the papular stage by continuous soaking 
with a solution of a mild antiseptic, such as boric or 
salicylic acid. 

Canquoin's paste and a solution of chloride of zinc, 
1 to 50, have been recommended for use in the same way 
as the carbolic acid. 

Extensive carbuncles are to be treated on surgical 
principles by incision or erosion with a curette. The 
resulting raw surface, as well as that of ordinary carbun- 
cles, is to be dressed antiseptically with iodoform, iodol, 
or aristol in powder. In all but the mildest cases the 
autogenous or stock staphylococcic vaccines should be 
used as detailed under Furunculosis, which see. 

Carcinoma. — Epithelioma is the form of cancer that 
most frequently is met with in the skin. It will be 
described under its proper heading. Carcinoma of the 
scirrhous variety rarely attacks the skin. When it does 
it may be primary or secondary. Most commonly it is 
secondary to the same disease of the breast or internal 
organs. It may follow extirpation of the primary deposit, 

1 British Med. Jour., 1898, ii, 1427. 

2 Lancet, May 19, 1888. 



138 DISEASES OF THE SKIN 

and then is prone to begin in the scar. Two varieties 
are described, namely: Carcinoma lenticnlare and Car- 
cinoma and tuberosum. 

Carcinoma lenticnlare generally appears on the chest 
in the neighborhood of the breast, and is secondary to a 
mammary cancer, or begins in the scar resulting from a 
previous operation for the removal of a cancer of the 
breast. It appears in the form of smooth, firm, glisten- 
ing, dull, white, or brownish-red or pinkish nodules 
raised above the surface and discrete at first. In size 
the nodules vary from that of a pea to that of a bean 
or larger. After a time the nodules run together and form 
a thick, indurated mass, which may involve so much 
of the chest as to interfere with breathing. This is the 
cancer en cuirasse of Velpeau. Now T the neighboring 
lymphatic glands are involved and the arm of the same 
side becomes swollen and useless. In a short time the 
nodules and the mass break down and ulcerate, and the 
patient soon dies of exhaustion. 

Carcinoma tuberosum is still more rare. It may occur 
anywhere, but is most frequently seen upon the face and 
hands. It takes the form of disseminated, flat or elevated, 
round or oval tubercles or nodules, seated deeply in the 
skin and subcutaneous tissues. These are of a dull-red, 
violaceous or brownish-red color, and may grow to the 
size of an egg. They do not tend to coalesce, though 
they may crowd closely together. They break down and 
ulcerate, and the patient dies just as in the lenticular 
variety. It usually appears in old people. 

In both forms there may or may not be lancinating 
pains, or there may be simply itching. In both, metas- 
tasis may take place. 

Carcinoma melanodes is described by most authors as 
a third form of carcinoma, but Robinson, Crocker, and 
Brocq regard it as melanotic sarcoma. It is impossible 
to distinguish them clinically from sarcoma, which see. 

Diagnosis. — The diagnosis of carcinoma is not difficult 
when one is aware that there is such a disease, and knows 



CHEILITIS EXFOLIATIVA 139 

that in a given case there has been, or is, a carcinoma 
elsewhere. The mode of evolution of the lesions, the 
involvement of the lymphatic glands, and the lancinating 
pains, all point toward carcinoma as against a tubercular 
syphilide, lupus, or leprosy. 

Treatment. — The treatment of carcinoma of the skin 
is the same as that of other forms, and is quite as unsat- 
isfactory. Massive doses of x-rays should be tried. 

Chafing. — See Erythema inter tigo. 

Chap. — Usually a mild form of eczema or dermatitis, 
the affected parts being red, possibly slightly swollen, 
and scaly. There often is superficial cracking of the 
epidermis, and these cracks sometimes bleed. The parts 
feel sore. It is generally due to exposure to cold and 
affects exposed parts, as the backs of the hands and the 
lips. It is predisposed to by a congenital dryness of the 
skin, owing to a deficiency of fat in its secretions. It 
may be caused by the use of strongly alkaline soaps, 
chemicals, and other irritants. Thorough drying of the 
hands after washing and keeping them covered from the 
air will prevent its occurrence on the hands. Rubbing 
into the skin cold cream from time to time, during the 
day or night, or the use of 1 drachm (4) of glycerin in 1 
ounce (32) of rose-water will prove curative. Avoiding 
wetting the lips, and making some greasy protecting 
application, such as camphor ice, will prevent the lips 
from being affected. 

Cheilitis Exfoliativa. — The vermilion border of the 
lower lip is the one most often affected, though the upper 
one may be. The lip is swollen and covered with a 
yellowish or brownish crust. If this is pulled off there 
will be exposed "a red glazed surface that may bleed. 
Cracking of the lips, with bleeding, may occur. A 
seborrheal dermatitis of the scalp may be found. It is 
regarded by some authorities as a seborrheal dermatitis. 
The cause is unknown. Its course is chronic, the disease 



140 DISEASES OF THE SKIN 

lasting for years. The daily application of camphor 
ice will keep the lips comfortable. Stel wagon benefited 
one case by using dilute, and later pure, lactic acid every 
six hours for four applications and repeating in ten days, 
an ointment containing ichthyol and acetanilid being 
used in the meantime. A solution of resorein may be 
tried. 

Cheilitis Glandularis Aposthematosa, or Myxadenitis 
Labialis, is a disease of the lips, usually the lower one. 
The lip becomes gradually swollen, firm, and rather hard 
to the touch, and its mobility is impaired. The mucous 
glands become swollen and can be felt as nodular masses. 
A turbid mucopurulent secretion is poured out at times, 
and the gland ducts are more or less dilated. No pain 
attends the disease, which is exceedingly obstinate to 
treatment. Black wash is recommended in the treatment, 
together with the occasional application of nitrate of 
silver. 

Cheiro-pompholyx. — See Pompholyx. 
Chilblain. — See Dermatitis congelationis. 

Chloasma. — Synonyms: (Fr.) Chloasme, Panne hepa- 
tique, Tache hepatique, Chaleur du foie, Masque; (Ger.) 
Pigmentflecken, Leberflecken; (Ital.) Macchie epatiche; 
(Eng.) Liver spot, Moth patch, Mask. 

A pigmentary disease of the skin, characterized by the 
formation of yellowish, brownish, or blackish patches of 
various sizes and shapes. 

Symptoms. — In this disease the only alteration of the 
skin is in its color. The disease consists in a deposit of 
pigment in the rete mucosum, and occurs in the form 
of circumscribed or diffused patches of yellowish to 
black discoloration. When the color is black it is called 
melasma or melanoderma. The size of the patches varies 
greatly from a small spot up to a general bronzing of 
the skin. 

The disease may be primary or secondary, idiopathic 



CHLOASMA 141 

or symptomatic. The idiopathic forms are most often 
secondary to some irritation. Thus it occurs with or 
in consequence of irritants applied to the skin, such 
as blisters or even sinapisms; prolonged scratching on 
account of some pruriginous disease, such as prurigo, 
pruritus cutaneus, chronic urticaria, scabies or pediculo- 
sis; exposure to the sun's rays or high winds, or even to 
heat, as of the furnace in iron workers, and then on 
exposed parts. These all cause more or less hyperemia 
of the skin, and besides the deposit of the pigment there 
is more or less discoloration from the changes taking 
place in the extra vasated blood. Allied to these causes 
and acting in the same way is the discoloration of the 
skin of the legs met with about old varicose ulcers and 
sometimes without the ulcers when there are marked 
varicosities. 

The symptomatic form may likewise be primary or sec- 
ondary. It is primary in that most common form of all 
that is known as Chloasma uterinum, or the mask, a 
hyperpigmentation of the skin of the face that occurs 
during pregnancy, or with uterine or ovarian irritation, 
and that is not met with after the menopause. It usually 
takes the shape of a diffused brownish, light or dark 
discoloration of the forehead alone, or also about the 
mouth and cheeks. Usually it extends only across the 
forehead and down the temples, and is either a continu- 
ous or interrupted patch with sharply defined borders. 
Sometimes it is macular in character and occurs on the 
eye-lids, lips, and chin. Under the same conditions there 
takes place a deepening of the color about the nipples 
and along the linea alba. The darkening of the color 
under the eyes of menstruating women is largely due to 
vascular congestion, and little, if at all, to chloasma. 
After a time in some women true chloasma does occur 
there. 

Primary pigmentation also occurs in certain cachexia?, 
such as Addison's disease, tubercular leprosy in Europeans, 
abdominal tuberculosis, cirrhosis of the liver, cancer of 



142 DISEASES OF THE SKIN 

the stomach, malaria, diabetes, exophthalmic goitre, and 
multiple melanotic sarcoma. There is also an earthy 
look to the skin in secondary as well as in congenital 
syphilis. Primary chloasma is also seen as the result 
of the ingestion of arsenic. Argyria is not a chloasma, 
strictly speaking. 

Secondary symptomatic chloasma is seen as the sequela 
of syphilides and of lichen ruber planus; these derma- 
toses disappearing to leave behind them, for a greater 
or less length of time, hyperpigmented spots. It may 
occur after other diseases of the skin, but then it usually 
is more fugitive. It is also seen in senile atrophy of the 
skin. There is hyperpigmentation about the patches 
of leukoderma and in scleroderma. There is also a 
pigmentary syphilide met with upon the neck in women. 

Etiology. — The cause of chloasma is undetermined in 
most cases. One theory to account for the pigmentation 
following exposure to the sun is that it is due to the 
action of the chemical rays of the sun upon the con- 
stituents of the blood. We know also that in some 
cases of hyperpigmentation following traumatism the 
color is due to changes taking place in the coloring 
matter of the extravasated blood. That there is a 
relation between chloasma uterinum and the sexual 
organs of women we know, because the chloasma usually 
clears away either after parturition, the cure of the 
uterine disorder, or the attainment of the menopause. 

Diagnosis. — The diagnosis is usually easy. Discolora- 
tions caused by artificial means can be washed off. 
Chromophytosis is scaly and can be scraped off with the 
nail. Chromidrosis is very rare and can be washed off 
with chloroform or ether. 

Treatment. — The treatment of chloasma is very 
unsatisfactory. In many of the symptomatic cases 
removal of the cause will be followed by disappearance 
of the color. Our first duty is to try to find the cause 
and, if possible, remove it. While it is possible to remove 
the color, it is very prone to return. Glacial acetic and 



CHROMIDROSIS 143 

trichloracetic acid touched on in dots will reduce the 
color and sometimes remove it. The same may be said 
of other acids, care being used not to cause too great a 
destruction of the skin by the stronger ones. The 
bichloride of mercury in 1 to 2 per cent, solution may be 
used for the purpose, applied repeatedly or else kept on 
continuously for three or four hours. This causes vesi- 
cation. The vesicle cover being removed the raw surface 
is to be dressed with a dusting powder. It is not always 
a safe procedure. Salicylic acid, 10 to 15 per cent., in 
ointment, paste, or plaster, or in saturated solution in 
alcohol, may do well. Resorcin, 20 per cent, in alcohol, 
applied repeatedly until the skin exfoliates, sometimes 
removes the pigmentation. Pure carbolic acid applied 
with a swab made of absorbent cotton on a small sharpened 
stick is one of the best applications. It turns the skin 
white, and in a few days the shrivelled epidermis falls. 
Unna has recommended washing the part with alcohol 
and applying overnight a mercurial plaster made with 
the ammoniate of mercury. The next day this is to be 
removed and the following ointment is to be applied : 



1$ — Bismuthi subnit., 








Kaolini, 


aa 


3iss 


aa 6 


Vaselini, 


ad 


oiss 


48 



M. 

Brocq advises a mercurial plaster during the night, 
bathing morning and evening with a 3 or 5 per cent, 
solution of bichloride of mercury, and wearing during 
the day oxide of zinc or bismuth ointment. 

The peroxide of hydrogen will cause a temporary dis- 
appearance of the pigmentation. Electrolysis may be 
used in small patches. In all cases in which there is an 
underlying cause attention must be given first to it. 

Pkognosis. — Many of the symptomatic pigmentations 
disappear when the patient recovers his health. It is 
not well to promise a certain disappearance of the patches, 
as some of them are permanent. 

Chromidrosis. — Synonyms: Ephidrosis tincta seu dis- 
color; Stearrhcea or Seborrhea nigricans; Pityriasis nigri- 



144 DISEASES OF THE SKIN 

cans; (Fr.) Cyanopathie cutanee, Melastearhee; Melan- 
hidrosis; Colored sweat. 

This is a condition in which the sweat has an abnor- 
mal color. Usually it affects only limited regions, espe- 
cially the lower eyelids. The color is most commonly 
blue or blue black. The subjects are most often hysteri- 
cal women, and many of the cases are feigned. 

Besides the lower eyelids the upper ones may be 
affected. Next in frequency the colored sweat forms on 
some other part of the face, but it may occur on any 
portion of the body, as in the axilla or groin. Besides 
the blue or black color, cases of yellow, green, brown, 
and even rose color have been reported. A few men have 
exhibited the phenomenon. Hoffmann 1 reports a case 
of blue sweat of the scrotum of a man seventy-two years 
old, and White 2 has met with an extensive case of yellow 
sweat in a man twenty years old. R. W. Taylor saw 
one case of apparently blue sweat that occurred in a 
man taking iodide of potassium, and w T as due to a reaction 
between the starch of his shirt and the iodine contained 
in the sweat. Constipation and nervous derangements 
are often found in the cases. The chromidrosis has been 
noted to grow worse with increased constipation, and 
become better when that condition was removed; to be 
more pronounced at menstrual periods, and to break 
out suddenly under emotional excitement. The skin 
may present no apparent change except the discolora- 
tion, or it may have an evident deposit, commonly 
greasy, upon it. In either case the color can be removed 
by wiping with a little oil, or scraped off partially with 
the finger nail. The condition may disappear spon- 
taneously or be persistent. Black pigment in the stomach 
contents, feces, and urine has been noted in some of 
the cases. 

Etiology. — The cause of the disease is obscure. Some 
instances are purely factitious. Blanchard 3 met with 

1 Wien. med. Wochenschr., 1873, xxiii, 291. 

2 Jour. Cutan. and Ven. Dis., 1884, ii, 293. 

3 Bull, de la Soc. Franc, de derm at. et de syph., 1908, p. 39. 



CHROMIDROSIS 145 

a case of black sweat that came after photophobia and 
conjunctivitis, and relapsed several times under the 
same conditions. It has been thought to be due to the 
presence of colorless indican in the sweat, which becomes 
blue by oxidation. This accounts for a few cases at least. 
Iodide of potassium is reported to have colored the sweat 
pink, and copper green. 

Diagnosis. — The diagnosis is easy because the dis- 
coloration can be readily removed by an oiled cloth, 
while that of chromophytosis does not so readily come 
off, and that of chloasma does not yield at all. More- 
over, neither of these last two conditions exhibits a 
blue color. 

Treatment.— It is important that constipation, men- 
strual disorders, or any derangement of health should 
be relieved. Locally, good results have been reported 
from the use of the following: 1 



1$ — Ac. borici, 




gr. x 




2 


Ac. salicylici, 




gr. xv 




3 


Ungt. aquse rosae, 


ad 


Sj 


ad 


100 



M. 

The red sweat that occurs in the axillae more especially, 
and elsewhere occasionally, is not a true chromidrosis, 
but is due to the growth of bacteria (bacillus prodigiosus) 
upon the hair, as may readily be demonstrated under the 
microscope. The bacteria are sometimes present so 
abundantly as to encrust the hair. The same bacteria 
grown on culture media are colorless, and it is supposed 
that the action of the sweat upon them determines their 
color. At times not only are the hair and skin stained 
red, but also the underclothing is deeply dyed. 

A mild parasiticide ointment or oil combined with the 
use of soap and water, or a simple borax solution, will 
cure the disease just as in chromidrosis. 

Green sweat has been seen in workers in copper and 
those taking the same by the mouth. Yelloio siveat has 
been found associated with bacteria and without them. 

1 Van Harlingen: Hand-book of Skin Diseases. 
10 



146 DISEASES OF THE SKIN 

Chromophytosis. 1 — Synonyms: Pityriasis versicolor; 
Tinea versicolor; Chloasma; Dermatomycosis furfuracea 
seu microsporina; Mycosis microsporina; (Ger.) Kleien 
Flechte; (Fr.) Pityriasis parasitaire ou versicolore. 

A vegetable parasitic disease, characterized by brown 
or cafe-au-lait colored, variously shaped and sized patches 
that occur chiefly upon the trunk. 

Symptoms. — This disease is far more common than 
statistical tables show it to be, as it causes so little trouble 
that many people never think of applying for relief. It 
begins as a small yellowish point, often located at the 
mouth of a follicle, which gradually grows into a split- 
pea-sized macular lesion. Many new lesions appear, 
and, these coalescing, patches form which may be so 
large as to occupy a great part of the chest or back. 
At first, when of small size, the patches are circular in 
shape, but as they grow larger they lose all definiteness 
of shape, though their edges are always sharply marked 
and sometimes raised. Annular patches sometimes 
form, and at other times there will be many more or 
less circular patches of sound skin in the midst of the 
diffused patch. The color is usually fawn or cafe-au-lait; 
it may be brown or even black. The latter is reported 
only from tropical countries. In warm weather and in 
those who sweat profusely it is no uncommon thing to 
see the eruption present a pinkish hue, due to hyperemia 
of the skin. In negroes the patches are gray or chamois- 
skin-like in color. The edge of the patch may be some- 
what raised, but the surface is not generally above that 
of the skin. It presents various appearances. At times 
it is smooth and feels greasy; at times it is dry and 
covered with fine branny scales; while at times it looks 
rough, and, viewed in the proper light, it presents an 
appearance resembling that of ichthyosis of mild grade. 
These appearances are dependent upon the amount of 

1 The name of chromophytosis was proposed for this disease by 
Dr. F. P. Foster, and has been well received in New York, as it quite 
accurately defines the disease and brings it in line with trichophytosis. 



CHROMOPHYTOSIS 147 

sweating, which, if profuse, will remove the scales, 
especially if the clothing rubs upon the skin. The greasy 
feel is imparted by the oily sebaceous matter, always 
marked in the region of the sternum, where chromo- 
phytosis most often is located. Whatever may be the 
apparent condition of the surface, scraping with the 
nail will remove a good part of the disease, showing 
that it is located in the upper layers of the epidermis. 

The patches are located chiefly upon the anterior 
surface of the chest and upon the abdomen. The back 
is also quite often affected, but not so markedly as the 
chest. In very extensive cases the arms and legs may 
show the disease, and a few cases have been reported as 
occurring upon the face. C. W. Allen pointed out that 
the disease is very often found concealed under the 
pubic hair. The rule is that the uncovered parts of the 
body are spared, and exceptions to this are very rare. 
The disease is not symmetrical. The number of patches 
varies from a few to hundreds. Left to itself it usually 
shows no tendency to recovery. 

The only subjective symptom is itching, and this is 
often absent, and seldom so bad as to cause the patient 
to seek relief on that account. Patients desire to be 
treated on account of the deformity, not the discomfort, 
of the disease. 

According to A. Castelani, 1 in the tropics there are 
three varieties of this disease. (1) Pityriasis versicolor 
flava, the most common, in which the patches are of 
various sizes, usually round, and smooth with sharply 
defined margins, sometimes festooned. The color varies 
from orange to canary yellow. Sometimes the patches 
have sound skin in the middle which may be intersected 
by yellow ribbon-like lines starting from the patches. The 
face, neck, chest, and abdomen are most often affected. 
It is only slightly scaly. It is chronic, often beginning 
in childhood and involving large areas. It is usually 

J Jour. Cutan. Dis., 1908, xxvi, 393. 



148 DISEASES OF THE SKIN 

seen only in Ceylon and India. (2) Pityriasis versicolor 
alba in which the patches are very light or white. (3) 
Pityriasis Versicolor nigra, in which the patches are dull 
black and lusterless. They may be small, round, and 
discrete or coalescent, and often are elevated and scaly. 
It affects mostly the neck and upper chest. This and 
the yellow variety may occur at the same time. 

Etiology. — The cause of the disease is the lodgement 
and growth in the corneous layer of the skin of a vege- 
table parasite, the microsporon furfur. Like all other 
parasites of its class, this one is incapable of growth on 
every skin. It flourishes especially upon the skin of one 
who sweats freely. That consumptives were thought to 
be especially prone to the disease is due to the fact that 
their chests are exposed to the physician more often than 
are those of any other class of patients, and the patches 
discovered. The disease is contagious, but its contagion 
is of low grade, and it is not common for it to take place 
even in such intimate relations as obtain between husband 
and wife. Adults from twenty to forty years of age are 
the most common subjects, though children may have 
the disease. According to Besnier and Doyon, the 
disease is never seen in very old people. It occurs in all 
countries, but most often in hot climates. It attacks 
all classes and conditions of men, and shows no particular 
discrimination in regard to sex. Its growth is interrupted 
by malarial paroxysms, and it peels off with the des- 
quamation of scarlatina and measles. 

Pathology.— The microsporon furfur is one of the 
most readily demonstrated of parasites. Place a few 
scales upon a slide, add a drop or two of liquor potassse, 
tease out the material a little, put on the cover-glass, and 
even with a low power the picture presented opposite 
will be seen (Fig. 16). It consists of heaps of conidia, 
which are larger than those of ringworm, with any 
quantity of interlacing mycelia running between them. 
Free conidia are scattered about in the field. The fungus 
grows in the upper layers of the epidermis. It has been 



CHROMOPH YTOSIS 



149 



asserted that there were two kinds of fungus, one brown 
and the other pale red, each of which produces its own 
colored eruption. In 1896 T. Spietschka succeeded in 
making a pure culture of the fungus, inoculating an 
individual with it, reproducing the disease and making 
pure cultures from it. In the tropical form of the dis- 
ease, the microsporon tropicum is found in the yellow 
variety; the microsporon Macfadyini in the white variety ; 
and the microsporon Mansoni in the black variety. 

Fig. 16 




Microsporon furfur. (After Kaposi.) 



Diagnosis. — If one remembers the characteristic feat- 
ures of the disease, yellow or cafe-au-lait, scaly patches, 
that can be partly scraped away and are located chiefly 
upon the trunk, little difficulty can arise in diagnosis. 
An appeal to the microscope will decide any doubtful 
question. Chloasma is not scaly, cannot be scraped off 
from the skin, and does not have spaces of normal colored 
skin in the midst of the patches. Leukoderma is an 



150 DISEASES OF THE SKIN 

absence of pigment with a hyperpigmentation about it 
that comes up to the white spot with a concave border 
and is not scaly. A fading erythematous syphilids occurs 
not in patches, but in isolated, round macules that 
are neither scaly nor itchy, that are usually most numerous 
over the abdomen and sides of the chest, and that are 
very often found as a disseminated eruption occurring 
upon the face as well as the trunk. Erythrasma is not 
so scaly and occurs usually only in or about the joints. 
Its parasite is much smaller than that of chromophytosis. 
Treatment. — Anything that will cause the removal of 
the upper layers of the epidermis will cure chromophy- 
tosis when present only in slight degree. But it is best 
for safety to use a parasiticide. One of the pleasantest 
ways of curing the disease is to have the patient scrub 
his skin thoroughly with soap and water, preferably 
soft soap, and then dab on, twice a day, a saturated 
solution of hyposulphite of soda, letting it dry on the skin. 
Crocker follows this with a solution of tartaric acid 5ij 
(8), water §viij (250), with the idea of producing 
nascent sulphurous acid on the skin. Sulphurous acid, 
pure or dilute, is a prompt remedy. Vleminckx's solution, 
1 to 3 or 6 parts of water; bichloride of mercury, 2 or 3 
grains to the ounce; or, as recommended by Klotz, 1 1 per 
cent, solution in tincture of benzoin; sulphur ointment 
rubbed in thoroughly, and tincture of veratrum viride 
are efficacious. The danger of systemic poisoning by 
either the bichloride of mercury or the veratrum viride 
should deter us from using these remedies in extensive 
cases. Brocq gives the following: 

~fy — Acid, salicylici, 2-3 parts. 

Sulphur, prsecip., 10-15 " 

Lanolini, 70 

Vaselini, 18 " M. 

Chrysarobin, naphtol, boric acid, and resorcin all are 
good. If the disease is very limited, it can be surely and 
speedily destroyed by painting the spot with tincture 
of iodin. 

1 Therap. Gaz., February, 1910. 



CLAVUS 151 

There is only one point to be borne in mind in using 
any of these remedies, and that is, that they must be 
thoroughly used and continued for a time even after the 
last trace of the fungus seems to have been removed. If 
one spore is left behind, the disease is liable to return. 
Special care must be given to the cure of the disease in 
the pubic region. The underclothing must be boiled 
before it is used again. Relapses are common, as the 
patient's skin is susceptible to the lodgement of the 
fungus. 

The black and white varieties of the tropics are readily 
cured by the application of a 4 per cent, alcoholic solution 
of salicylic acid, followed by ungt. hydrarg. ammon. 
The yellow variety is obstinate to treatment, but is 
curable by the persistent use of turpentine applied 
daily, followed by a naphtol or epicairin ointment. 

Clavus. — Synonyms: (Fr.) Cor; (Ger.) Leichdorn, 
Hiihnerauge; Corn. 

Symptoms. — Corns are circumscribed hyperplasias of 
the corneous layers of the skin due to intermittent pres- 
sure usually from badly fitting shoes, and differing from 
calluses in having a central core that grows down toward 
the corium. They usually occur upon the toes, either 
over prominent joints, where they form hard corns; or 
between the toes, where on account of being kept moist 
they form soft corns. They are usually conical in shape 
and slightly projecting. Unless pared down they become 
painful on account of their central core being pressed 
into the cutis. They are sometimes spontaneously 
painful on the approach of wet weather on account of 
their being hygroscopic. They may suppurate. They 
may occur upon the palm. We have seen several cases 
in tennis players. The soles are sometimes affected 
with them, especially in people with flat-foot, and then 
walking is rendered very painful. 

Treatment. — The best treatment for corns is to wear 
well-fitting boots and shoes of the straight last pattern, 



152 DISEASES OF THE SKIN 

which must be neither too large nor too small. Pointed- 
toed and high-heeled shoes are especially apt to cause 
corns. The corn may be removed by the use of a salicylic 
acid plaster, or by Vigier's preparation, now sold under 
the name of Hebra's Corn Remedy, which is composed of: 



1$ — Ac. salicylici, 


gr. xx 


1 


5 


Ex. cannabis indicae, 


gr. x 




75 


Alcoholis, 


TTlxx 


1 


5 


iEtheris, 


lUlxxx 


5 


5 


Collodion flex., 


ad gss 


16 


M 



which is to be painted on twice a day for three or four 
days ; then the feet are to be soaked in hot water, and the 
corn picked out. Corns may also be cut out, but the 
operation is at times dangerous, especially in old people. 
They may be pared down and pressure removed from 
them by means of felt rings which come for the purpose. 
J. F. Palmer 1 believes that cutting corns tends to increase 
their size, and advises soaking the feet morning and 
night in warm water, with or without carbonate of soda, 
bread poultices at night, and woollen socks with a felt 
ring over the corn by day. Resorcin plaster of 10 per 
cent, strength worn for some days will remove corns. 
Crocker recommeds for soft corns careful daily ablution 
with soap and water, painting on them spirits of cam- 
phor at night, and wearing lambs' wool between the toes 
during the day. The ointment of the nitrate of mercury 
and touching with nitrate of silver are recommended for 
soft corns. Bicarbonate of soda, the dry powder, applied 
to the corn and the toes kept separated with lambs' wool 
is a good treatment. Absorbent cotton should never be 
used between the toes, as it absorbs the moisture, becomes 
stringy, and renders matters worse. Zeisler has cured one 
case with x-rays. But unless well-made shoes are worn 
the corns will be sure to return. Corns on the hands may 
be removed with salicylic acid or scraped out with the 
dermal curette. 

1 Clin. Jour., 1906, xxviii., 284. 



COLLOID DEGENERATION OF THE SKIN 153 

Clavus Syphiliticus. — Under this title Lewin 1 describes 
certain lesions that he regards as being syphilitic. They 
are horny, elevated growths that occur upon the hands 
and feet, and are sometimes surmounted by a delicate 
scaly crown, and sometimes covered with scales. They 
are from pinhead to lentil in size; circular, oval or oblong 
in shape; flat or concave on top, but never convex, and 
appear as if wedged into the skin. At first they are pale 
red and soft, but later they become yellowish horn color 
and hard. They are usually on the palms of the hands, 
but may be on the soles of the feet, as well as upon all 
surfaces of the fingers and toes. There is no pain caused 
by them. There may be some itching. The lesions are 
met w T ith in both sexes, and occur early in the disease, 
and often symmetrically. 

Cold Sore. — See Herpes facialis. 

Colloid Degeneration of the Skin. — Synonyms: Colloid 
milium; (Ger.) Hyaloma der Haut; (Fr.) Hyalome cutane. 

Symptoms. — This is a very rare disease of the skin 
that occurs most often on the upper part of the face in 
the form of disseminated or grouped, discrete, trans- 
parent, shining, rounded, lemon-yellow elevations of the 
skin. They have been seen on the backs of the hands, 
neck, and arms. Though they look as though they were 
vesicles, they do not contain fluid, and when pricked 
give exit to only a small amount of gelatinous substance 
and a drop or two of blood. They vary in size from 
a pinhead to a split-pea. They are resistant to the 
touch. The course of the disease is slow. It is capable 
of spontaneous disappearance by absorption or inflam- 
mation, leaving an ill-defined mark on the skin. It 
affects both sexes. The youngest patient so far reported 
was fifteen years old. It usually occurs in adult life, 
and seems in most cases to be due to exposure to the 
weather. It is the result of a degeneration of the fibrous 

1 Arch. f. Dermat. u. Syph., 1893, xxv, 3. 



154 DISEASES OF THE SKIN 

elements of the corium. There are no subjective symp- 
toms, and the general health is good. 

Diagnosis. — It differs from xanthoma in its trans- 
parency and in the shining appearance and lemon-yellow 
color of the lesion. In xanthoma the lesions are soft and 
of a dull yellow. In hydrocystoma the lesions are more 
crystalline in appearance, and when pricked a drop of 
pure watery fluid escapes from them. In adenoma 
sebaceum the lesions are markedly vascular in places 
and the disease begins in early life. 

Treatment consists in removing them by the curette 
or electrolysis. 

Comedo. — Synonyms: Acne punctata, Acne f ollicularis ; 
(Fr.) Comedon, Acne punctuee, Tanne; (Ger.) Mitesser, 
Hautwurmer; Grubs, Fleshworms, Blackheads. 

A comedo is a collection of inspissated sebaceous mat- 
ter retained in a pilo-sebaceous gland, whose mouth is 
closed by a brown or black-topped plug, and appears 
as a pinpoint- to a pinhead-sized, slightly elevated, 
conical papule in the skin. 

Symptoms. — Comedones are met with most often upon 
the face, ears, back, and shoulders, and occasionally, but 
much more rarely, on other parts of the body. Wherever 
met with they present the characteristics indicated 
in the definition just given. They are unaccompanied 
by inflammatory symptoms. Just as soon as inflam- 
mation is caused by their presence they are converted 
into acne lesions^a change that they very commonly 
undergo. Usually they are scattered about irregularly; 
sometimes they are grouped in certain regions. They 
are single lesions in the vast majority of cases, and being 
pressed between the thumb-nails they are readily ex- 
pressed in the form either of an ovoid mass or more 
commonly as a filiform or worm-like mass that may be a 
half-inch or more in length, and has a black head that 
obtains for them the popular names of "fleshworms" 
and "blackheads." Very exceptionally they are double, 



COMEDO 155 

lateral pressures queezing out a filiform mass with a black 
head at both ends, if such an expression is allowable. 
There may be but few, or there may be hundreds of 
them, so that the skin looks as if sown with grains of 
gunpowder. The largest are found in the ears and on 
the back. They give rise to no subjective symptoms. 
Seborrhela is frequently a marked complication. 

In chidren they are more apt to be grouped, and, 
according to Crocker, to appear on the forehead and 
occiput of boys, the temples in girls, and the cheeks in 
infants. The scalp, too, is in children the seat of the 
disease. Acne may follow them. 

Etiology. — All that has been said as to the causes of 
acne applies with equal force to comedones, and need 
not be repeated here. We would only add that Unna 1 
does not accept the commonly received doctrine that the 
blackhead and the clogging of the follicle are largely 
due to extraneous matter, but teaches that they are due 
to the corneous layer of the skin being abnormally firm 
and preventing the escape of the follicle contents by 
growing over its mouth. The black color he believes 
to be analogous to the coloration of horns in cattle. 
He calls attention to the fact that comedones are more 
frequent in chlorotic girls than in coal-heavers. 

It is quite certain, however, that many cases of come- 
dones are directly due to dirt or other foreign matters 
stopping up the follicles. Contact with tar acts in the 
same way. This is supposed to be especially the case 
in children. Colcott Fox 2 says that in them the come- 
dones are found most often in the spring-time and disap- 
pear in the winter. The youngest case in a child is one 
at twelve months of age. 3 

Pathology. — The pathology of the affection is the 
same as that of acne without the evidence of inflam- 
mation. We find many varieties of microorganisms in 

1 Virchow's Archiv, 1880, lxxxii, 175. 

2 Lancet, 1888, i, 665. 

3 Crocker: Lancet, 1884, i, 704. 



156 



DISEASES OF THE SKIN 



Fig. 17 



comedones. Sabouraud believes that the microbacillus 
is the cause of comedones. These bacilli form cocoons 
in the mouths of the sebaceous glands and occlude them. 
The demodex folliculorum, a harmless parasite, is very 
often found in the plugs of sebaceous matter. It is long 
and worm-like, with a head, a thorax with four pairs of 
short, conical, three-jointed feet, with 
minute claw-like extremities, and a 
long, tail-like abdomen, which tapers 
off into a blunt and rounded point 
(Fig. 17). _ 

Von During 1 has endeavored to show 
that the double comedo is always an 
acquired formation, and is the result 
of a destructive process between the 
ducts of two neighboring glands, so 
that the two ducts become one, and 
that the destructive process has af- 
fected only one gland, while the other 
one is still active enough to produce 
the comedo plug. 

Diagnosis. — There is little diffi- 
culty in recognizing the disorder. 
Powder grains in the skin are under 
the skin and cannot be squeezed out. 
Treatment. — The same constitu- 
tional conditions being met with in 
comedones as in acne, we need not 
repeat here what is said there in 
regard to the general treatment. 
The local treatment consists in press- 
ing out the comedones and stimulating the skin to a more 
healthy action. There is little use in doing the first without 
the second, as the comedo would be sure to re-form. The 
comedones come out most readily after the free use of soap 
and warm water. Then they may be pressed out between 



Demodex folliculo- 
rum. (After Kuchen- 
meister.) 



Monatshefte f. prakt. Dermat., 1888, vii, 401. 



COMEDO 157 

the thumb nails, or by means of an old watch key, whose 
sharp edges have been worn down; or by means of a 
comedo presser or preferably the comedo scoop of Fox 
(Fig. 18). With some practice they may be removed 
by pressing the back of a small dermal curette against 
one side of the follicle mouth and making a quick turn 
of the end about them. Violent attempts at removal 
should not be made, as they may cause inflamma- 
tion on account of too much irritation. If the comedo 
does not come out readily, wait until another time. 
Stelwagon 1 advises the use of the faradic current two or 
three times a week. Also the daily use of a small cupping 
glass. 

Fig. 18 



Fox's comedo scoop. 

Frictions with green or soft soap and water are excel- 
lent as a stimulating remedy, care being taken not to set 
up too much reaction. Hardaway recommends: 



1$ — Saponis olivse prseparat., 

Alcoholis, aa 5j aa 25 

Aquae rosse, ad 5vj 150 



M. 



To be rubbed in with a piece of damp flannel every 
night. He regards the use of sulphur preparations as 
tending to cause comedones, and hence objectionable. 
Alcoholic and astringent lotions of boric acid, alum, or 
zinc may act well to close up wide-open pores. 

Sulphur and most of the preparations given under 
acne are useful. At times the sulphur preparations 
seem to increase the trouble, especially in winter time, 
when there is more or less coal gas in the house from 
stoves and furnaces, and have to be abandoned in favor 
of mercurials as in acne. 

1 Diseases of the Skin, Philadelphia, 1914. 



158 DISEASES OF THE SKIN 

The best prophylactic measure is the daily washing of 
the face with soap and water, combined with massage. 

Corn. — See Clavus. 

Cornu Cutaneum vel Humanum. — Synonyms: (Ft.) Corne 
de la peau; (Ger.) Hauthorn; Cutaneous horn. 

This is a rare disease of the skin, in which there grows 
a horn-like excrescence resembling, often in a most 
striking manner, an animal's horn. Horns vary greatly 
as to size. They are of very slow growth and may attain 
the length of a foot and a diameter of fourteen inches 
at the base. They are usually single, but may be multiple. 
They may be straight, but usually are bent or twisted; 
they may be laminated, striated, or fibrillated; they may 
be yellowish, dirty gray, green, brown, or black; they 
are solid and hard, but not smooth and shining like 
animals' horns often are; and they have rounded or 
truncated ends. About their base there may be some 
sign of inflammation. They are not painful unless pressed 
on. When torn or knocked off they expose a raw and 
bleeding surface at the base. Sometimes they fall spon- 
taneously or as the result of some inflammatory process. 
Usually they re-form. Most of them occur upon the head, 
nose, face, or scalp. They may occur elsewhere, as upon 
the extremities or male genitals. Their base may become 
the site of epithelioma. 

There is little known about their etiology. They may 
occur at any age and in either sex. The poorer classes 
are more often affected than the well-to-do. Most 
cases occur after the fortieth year of life. They seem 
to be warty growths that have undergone corneous 
transformation. 

Pathology. — In the early stages the growth may be 
seen to consist of a group of elongated and hypertrophied 
papillae, upon which the epithelial cells have undergone 
keratosis. At the base of the horn and in the papilla 
are numerous telangiectatic bloodvessels. 

Treatment. — The treatment consists in tearing them 
off, under an anesthetic if large, curetting the base, and 



CYST, DERMOID 159 

applying a caustic, such as chloride of zinc paste, pyro- 
gallic acid, or acid nitrate of mercury. 

Craw-craw is a disease of uncertain nature, met with 
in the tropics, especially on the west coast of Africa. 
It may be papular, vesicular, or pustular, the lesions 
being disseminated or grouped. Itching accompanies 
the lesions, and crusts form from scratching. Ulcera- 
tion sometimes takes place. Both whites and negroes 
are attacked, but chiefly the latter. Several kinds of 
parasites have been found in connection with the disease, 
especially a species of filaria. 

The treatment consists in the removal of the crusts 
and erasion of the soft tissues beneath, as well as of all 
other lesions, and the application of an antiparasitic. 

Creeping Eruption. — See Hyponomoderma. 

Cutis Anserina, or Goose Flesh, is that condition of the 
skin in which, on account of the action of cold, causing a 
contraction of the arrectores pilorum muscles and eleva- 
tion of the hair follicles, it feels rough and looks as if 
studded over with minute papules. It is a fugitive 
affair, therein differing from keratosis pilaris, which, 
though resembling it, is constant. 

Cutis Verticis Gyrata is the name given by Jadassohn 
and Unna to a peculiarity of the scalp in which it is 
thrown into folds resembling the convolutions of the 
brain. A case is reported by K. Vignolo-Lutati 1 which 
apparently followed a slight injury to the scalp. He 
thought it was due to the development of a deep sclerotic 
condition in parts of the scalp producing the deep lines. 

Cyst, Dermoid. — These are usually single lesions, and 
look like fibromas. But when they are opened they 
give exit to sebaceous-looking matter. Hair and teeth 
are frequently found in them. They are supposed to 
be remains of fetal structures. If single, they can be 
excised. 

1 Archiv Dermat. u. Syph., 1910, civ, 421. 



160 DISEASES OF THE SKIN 

Cyst, Sebaceous. — Synonyms, Atheroma, Steatoma, Wen. 

These innocuous little tumors may occur anywhere on 
the body, but are most common on the scalp, face, neck, 
back, and scrotum. They vary in size from that of a 
millet seed to that of an orange. They may be rounded, 
flattened, or hemispherical. There will be found in 
many of them a small opening, out of which some of 
their contents may be pressed. The skin over them may 
be of normal color, pale on account of pressure, or red 

Fig. 19 




Sebaceous cysts of scalp. (Hyde.) 

if the cyst becomes inflamed. They may be elastic and 
doughy to the touch, or firm, or soft, according to the 
condition of their contents, which may be fluid and honey- 
like, or cheesy. They tend to grow slowly, and give no 
trouble except by the deformity they cause. In excep- 
tional cases they may become inflamed and ulcerate. The 
hair is usually absent over them when they occur on the 
scalp. 

Etiology. — Most cysts are due to distention of a 
sebaceous gland. They occur in both sexes in adult 



DERMATALGIA 161 

life, being rare in children. Considerable uncertainty 
surrounds their pathology. 

Diagnosis. — They must be distinguished from fatty 
tumors and gummata. Fatty iumors are firmer and more 
doughy than cysts, and are more often tabulated, occur 
but seldom on the scalp, and are rarely multiple. Fibro- 
mas are commonly multiple, are of firmer consistence, 
and rarely assume a lobular shape. Syphilitic gummas 
are more rapid in their growth, are attached to the skin, 
and tend to break down and ulcerate. 

Treatment. — The tumor is to be opened by a linear 
incision, and the contents emptied out, special care being 
taken to remove the lining membrane of the sac entire. 

Cysticercus Cellulosse Cutis. — At times the larvae of the 
tapeworm become lodged in the subcutaneous tissues and 
produce movable, painless, round or oval, pea- or cherry- 
sized tumors, with the skin raised over them. They are 
smooth, firm, and elastic. The larger ones may feel like 
wens. After about eight months (Cobbold) the animals 
die, and the tumors shrivel up and become hard nodules, 
or they may be absorbed. They simulate gummas, lipo- 
mas, sarcomas, carcinomas, and sebaceous cysts. In a 
doubtful case excision or puncture of one of the tumors 
will show under the microscope either one of the larvae 
curled up in its shell, as it were, or the hooklets in the 
fluid that escapes. 

Dandriff or Dandruff. — See Pityriasis steatodes. 
Darier's Disease. — See Keratosis follicularis. 
Defluvium Capillorum. — See Alopecia. 
Delhi Boil. — See Aleppo boil. 

Dermatalgia. — Synonyms: (Fr.) Dermalgie; (Ger.) 
Hautschmerz, Hautnervenschmerz; Neuralgia or Rheu- 
matism of the skin. 

By this term is meant spontaneous pain in the skin, 
without any appreciable alteration of the same. The 
pain is variously described by patients as boring, pricking, 
11 



162 DISEASES OF THE SKIN 

or burning; or numbness or coldness may be complained 
of. It is constant or intermittent in character and some- 
times so severe as to be agonizing. It may be excited 
by the slightest contact. It is generally sharply located 
in a certain region, but may be general. The hairy parts 
are those most often affected, as the scalp. The legs and 
back, and palms and soles are not infrequently involved, 
as may be any part. Hyperesthesia or anesthesia may 
be present at the same time. Deep pressure may or 
may not relieve it. It disappears of itself after weeks 
or months. 

Causalgia is one form of dermatalgia. The patient 
complains of a burning pain, and of tenderness, and the 
area supplied by the affected nerve may have a glossy 
appearance. 

Etiology. — It is a neurosis that may be idiopathic 
or symptomatic. The idiopathic form is rare, and its 
etiology obscure. The symptomatic form occurs in 
dyspepsia, locomotor ataxia, rheumatism, syphilis, 
malaria, diabetes, hysteria, chlorosis, and after zoster. 
According to Hyde, it may be a sign of the approaching 
menopause. The majority of its subjects are women. 

Diagnosis. — Dermatalgia differs from neuralgia in 
being more superficial and in being accompanied by 
hyperesthesia. It differs from hyperesthesia in being a 
spontaneous pain, while the latter is pain only upon 
contact. 

Treatment. — If we can remove the underlying cause 
we shall cure the trouble, so our remedies should first 
be addressed to it. In any case the patient demands 
something to relieve the pain. In the way of internal 
remedies we can use the salicylates, quinin, antipyrin, 
phenacetin, some form of opium, hyoscyamus, valerian, 
and other like drugs. Externally relief may be obtained 
by galvanism, blistering, a mustard leaf over the centre 
from which emanates the nerve (Crocker), hot or cold 
water in a rubber water bag, either alone or alter- 
nately; rubbing in oleate of morphin, menthol pencil, 



DERMATITIS BLASTOMYCOTICA 163 

chloroform liniment, tincture of aconite, and the like. 
Galvanism and the high-frequency current may be 
tried. 

Dermatitis Blastomycotica. — Under the name of pseudo- 
lupus or blastomycetic dermatitis, T. C. Gilchrist and 
W. R. Stokes 1 described a disease that had been recognized 
for a long time and regarded as a lupus, or at least a 
scrofuloderm. Since the publication of their observations 
cases of the disease have been reported by dermatologists 
of the United States and Europe. 

Symptoms. — The disease usually begins as a split-pea- 
sized round papule which may change into a pustule. 
New lesions crop up peripherally and run together so as 
to form a patch; or the original lesion slowly enlarges so 
as to form a patch. The patch is elevated from one- 
eighth to three-eighths of an inch; the surface is covered 
by irregular papilliform elevations separated by fissures 
of varying depths, giving it a verrucous or cauliflower 
appearance. In young patches and near the border of 
old ones the papillary projections are fine and the surface 
fairly firm, dry, and wart-like. Untreated areas are 
covered by more or less bulky crusts, which on removal 
expose a papillary surface bathed with a seropurulent 
secretion. Some of these patches are very vascular and 
bleed easily. They are deep red in color. Exceptionally 
we find ordinary unhealthy ulcers with exuberant granu- 
lations. The papillomatous surface may be replaced 
partly with an elevated scar-like surface, pinkish white, 
irregular, smooth, and shining. 

One of the most characteristic features of the disease is 
the border of the patch. It slopes more or less abruptly 
toward the normal skin, and is sharply defined, smooth, 
dark red or purple, from one-eighth to three-eighths of 
an inch wide, and strewed over with a large number of 
minute abscesses. These may be superficial or deep, and 

1 Johns Hopkins Hosp. Rep., 1897, viii, 46, and Jour. Cutan. and 
Gen.-Urin. Dis., 1897, xv, 393. 



1(34 DISEASES OF THE SKIN 

when punctured give exit to a small amount of thick, 
glairy mucus or mucopus. Abscesses of the same char- 
acter are found elsewhere on the patch. 

The course of the disease is chronic. It takes several 
months for a patch to attain the diameter of an inch. It 
may remain stationary for a long time, but usually 
extends slowly and continuously. In course of time new 
patches crop up in the vicinity of the original patch or 
elsewhere. Patches may be as large as the palm or 
larger. Healing takes place in the centre of the patch 
by a flattening of the papillary projections, a lessening of 
the secretion, and the assumption of a verrucous appear- 
ance. Eventually it cicatrizes, producing a smooth, soft, 
inconspicuous scar. A recrudescence of the disease in 
the scar at times occurs. 

The disease occurs most often on the exposed parts, 
the face, neck, hand, wrist, and lower extremities. Some 
of the patients remain in fair health, some die of tubercu- 
losis, and some from systemic infection by the blasto- 
mycetes. 

Etiology. — Invasion of the skin by the yeast fungus 
is the cause of the disease. The majority of the patients 
are men, and most are of middle age. J. B. Kessler 1 
has reported a case in a child five months old. Tuber- 
culosis was present in some of the patients. 

Pathology. — There are many miliary abscesses in 
most of which the fungus is found. There are also 
hypertrophy of the epithelial layer of the skin a large 
number of polymorphonuclear leukocytes, and giant cells 
resembling those found in tuberculosis. 

The parasites are found most frequently in the pus 
from the miliary abscesses. They have a capsule, a trans- 
parent zone, a central protoplasmic mass, and a vacuole 
within the protoplasm. The organism multiplies by 
budding, the buds being of all sizes, several often start- 
ing from the mother body at the same time. 

1 Jour. Amer. Med. Assoc, 1907, xlix, 550. 



DERMA TI TIS B ULLOSA 



165 



Diagnosis. — From tuberculosis verrucosa cutis, blasto- 
mycetic dermatitis differs in its more rapid course, its 
wider spread, and the halo about it being less violet in 
color. But an appeal to the microscope is the only 
reliable means of diagnosis. 

Treatment. — The iodide of potassium in large doses, 
from 200 to 500 grains a day, exerts a remarkably ame- 
liorating influence on the disease, but radical destruction 

Fig. 20 Fig. 21 





Budding organism in tissue. X 1200. Hanging drop. X 1200 

Blastomycosis of the skin. (Hyde and Montgomery.) 1 



of the patch by the curette or its ablation by the knife is 
the most reliable curative agent. The .r-rays have seemed 
to help some cases when used in conjunction with iodide 
of potassium. 

The prognosis is bad if blastomycotic septicemia sets 
in. Otherwise a cure should result if the disease is sub- 
jected to treatment early in its course. 

Dermatitis Bullosa. — See Epidermolysis. 

1 Courtesy of Drs. Hyde and Montgomery. 



166 DISEASES OF THE SKIN 

Dermatitis Calorica is the inflammation of the skin 
produced by heat or cold, and divides itself naturally 
into two divisions, viz., D. ambustionis and D. congela- 
tions. 

Dermatitis ambustionis is the effect of heat upon the 
skin, the source of the same being either natural, as from 
the sun, or artificial. According to the intensity and 
prolonged action of the heat and the resistance of the skin 
will be the damage inflicted on the skin. A slight degree 
of beat gives rise to a passing erythema. Burns are due 
to a great amount of heat, and are described for conve- 
nience as being of three degrees. In the first degree the 
skin is reddened, hot, and somewhat swollen; in the 
second the damage is greater and vesicles and bullae are 
formed; and in the third, there is complete destruction 
of the skin followed by gangrene. There is always 
considerable pain with any burn, and, if of great ex- 
tent, rise of temperature and shock. Extensive burns 
may be dangerous to life even if not of very high degree, 
and burns involving one-half the cutaneous surface are 
generally fatal. The cause of death in such cases is 
uncertain. One theory, as put forth by Lustgarten, 1 is 
that it is due to a toxin developed by the lodgement of 
microorganisms of putrefaction upon the eschar, prob- 
ably a ptomain similar to muscarin. Some of the other 
theories are nerve shock, ulcerations of digestive tract, 
nephritis, decomposition of the red-blood globules; but 
no one of these is satisfactory in all cases. 

Treatment. — The treatment of severe burns com- 
monly falls into the hands of the surgeon. The general 
condition of the patient must be cared for, as he is often 
in a state of shock. In simple burns the pain may be 
relieved by painting them with a 5 to 10 per cent, solution 
of cocain, and then applying carron oil, consisting of 
equal parts of linseed oil and lime-water, to which may 
be added 5 per cent, of carbolic acid, absorbent cotton 

1 Med. Rec, 1891, xl, 152. 



DERMATITIS CALORIC A 167 

being soaked with the oil laid over the burn and covered 
with impermeable rubber tissue. This forms an admirable 
dressing that may be left on for several days, if care is 
taken to disinfect the part thoroughly before applying it. 
From time to time the rubber tissue may be removed 
for a moment and fresh carron oil applied. If this is 
not at hand, the part should be dusted thickly with flour 
or corn starch until it is procured. Or the burns may be 
covered with a varnish of linseed oil and wax, contain- 
ing 5 per cent, of salicylic acid. Or they may be pow- 
dered with bicarbonate of sodium or any of the anti- 
septic powders. Or the bullae and vesicles may be 
opened and the surface painted with a 2 to 5 per cent, 
solution of picric acid or a solution of ichthyol in 
water, 1 in 1 to 1 in 4 may be painted on. Fancher 1 
advises against puncturing the blisters, and in favor of 
spraying the part with peroxide of hydrogen, mopping 
with gauze and laying over it strips of gauze soaked 
in picric acid, 3j (4), alcohol, gij (64), water Oiss (768), 
and applying over all absorbent cotton and a loose roller 
bandage. This dressing is to be left on until soiled, and 
then repeated. The excess of fluid is to be drained off 
and the surface covered with rubber tissue or soft gauze 
that is to be left on for tw^o or three days. Deep and 
extensive burns must be treated on surgical and strictly 
antiseptic principles. Lustgarten, in the paper referred 
to, recommends the administration of atropin as a 
physiological antagonist to the ptomain, the removal 
of necrotic portions of skin, and dressing the wound 
with carbonate of magnesium, 1 part, and oleum rusci, 
2 parts. All cases of any magnitude demand absolute 
rest in bed. The continuous water-bath of Hebra is 
excellent where it can be had. 

In sunburn the application of cold cream and a dust- 
ing powder or calamin lotion is usually sufficient. As 
a preventative the skin may be anointed with the grease 

1 Jour. Amer. Med. Assoc, 1910, xlvi, 27. 



168 DISEASES OF THE SKIN 

paint used by actors, preferably one of brown color. A 
calamin lotion, used freely, is one of the most efficient 
and agreeable agents for preventing sunburn. 

Dermatitis congelationis, or " frost-bite," is the action of 
cold upon the skin. Like heat, cold produces varying 
degrees of damage to the skin; if not very intense, the 
effect is an erythema — "erythema pernio," "chilblain" 
— which is passing. These are seen upon the hands, 
feet, and face as bluish or purplish-red, circumscribed 
patches, which are cool to the touch, but are accom- 
panied by a feeling of heat, smarting, itching, or burning, 
both while forming and when the parts again become 
warmed. To those predisposed to chilblains, dampness 
accompanied by only very moderately cool temperature 
is sufficient to produce them. Hutchinson speaks of 
the "chilblain diathesis" to indicate the condition found 
in these people. Their circulation is poor, and they are 
anemic. Greater degrees of cold at first cause the parts 
to become white, dead, and wrinkled. When the cold 
is lessened redness and swelling supervene. Longer 
exposure may produce bulla? and vesicles or gangrene, 
either on account of prolonged anemia or inflammatory 
reaction from too sudden warming. Fingers, toes, 
nose, or ears may be lost in consequence, mortification 
setting in. Death may result from septicemia. 

Treatment. — The best preventive treatment of chil- 
blains is the wearing of woollen coverings on the affected 
parts and endeavoring to improve the general health of 
the patient and to quicken his circulation. To the latter 
end we may use w T arm foot-baths, containing salt, at 
night, followed by frictions with alcohol. Whitfield 
recommends giving opium in small doses, or nitroglycerin, 
tfu" § r v t. i. d. He advocates the use of w T eak galvanic 
currents, placing, the negative pole at the nape of the 
neck and the positive pole in a basin of warm water, in 
which the hands are placed; if the feet are affected they 
are to be put in the water and the negative pole at the 
lumbar region. A current of 5 ma. is to be used for 



DERMATITIS EXFOLIATIVA 109 

ten minutes. When they occur stimulation is necessary, 
for which we may use iodin, either in tincture or oint- 
ment; ichthyol, 20 to 50 per cent, in water or equal parts 
of camphor and belladonna liniment; or — 



I£ — 01. cajuputi, 

Liq. amnion, fort., aa 3 i.i aa 8 

Sapo. liniment, co., ad giij ad 100 



M. 



or simple frictions. Care should be taken in severe 
frost-bites not to allow the parts to become warm too 
rapidly, and nothing is better than rubbing them with 
snow while the patient is kept in a cool room. When 
sloughing or ulceration has begun it must be treated on 
surgical principles. 

Dermatitis Exfoliativa. — Synonyms: Pityriasis rubra 
(Devergie and Hebra); Eczema folicaeum seu exfoliati- 
vum; (Fr.) Dermatite exfoliatrice ou exfoliative general- 
isee, Herpetide exfoliative; Erythrodermie exfoliante. 

An inflammatory disease of the skin involving the 
whole cutaneous surface, and characterized by redness, 
dryness, and abundant desquamation. 

The terms dermatitis exfoliativa and pityriasis rubra 
are used interchangeably by most authorities of the pres - 
ent time. If one reads the description of pityriasis rubra 
as given by Hebra, and of dermatitis exfoliativa as given 
by Wilson, he will find that the chief difference between 
them is in prognosis, the first being spoken of as uni- 
formly fatal, and the second as tending to recovery in 
many instances. Further, there are not a few cases of 
general exfoliating dermatitis that follow psoriasis, 
eczema, pemphigus foliaceus, and lichen ruber, that 
present symptoms identical with those of dermatitis 
exfoliativa without antecedent disease. It seems justi- 
fiable, therefore, to divide dermatitis exfoliativa into 
two varieties, namely, a primary and secondary. 

1. Primary dermatitis exfoliativa or Pityriasis rubra of 
Hebra. 



170 DISEASES OF THE SKIN 

Symptoms. — This disease begins as one or more ery- 
thematous patches in the folds of the joints, upon the 
upper part of the chest, or elsewhere, and these patches 
gradually enlarge. At the same time new patches 
develop, and, increasing in size, join the original ones. In 
this way the whole surface may become red within three 
days, or a month or more may elapse before the whole 
surface is implicated. The palms and soles may be 
unaffected for days or weeks. The skin is dry and of a 
bright red at first, without thickening and infiltration, 
the redness lessening and leaving a yellow stain on 
pressure. In a few days, say from six to twelve, scaling 
begins and the skin becomes of a darker red; it may even 
become violaceous. The scales may be large, thin, 
grayish, attached at their upper border and loose else- 
where, being turned up at their edges. They may be small 
and adherent in the centre. The amount of scaling is so 
great that handfuls of scales may be gathered from the 
bed after a night's rest. After a few weeks the epidermis 
may be raised and shed from the hands and soles in the 
form of a continuous sheet, sometimes forming a complete 
cast of the part and leaving a red, dry, glazed surface. 
There is a marked enlargement of the glands in the groin, 
so that the whole packet of glands stands out prominently 
against the red skin. The disease is chronic and the 
scaling constant, though marked with exacerbations. 
After lasting some time there is a certain amount of 
infiltration of the skin, and it seems to grow too small 
for the body and looks stretched and shiny in places. 
Thus are produced ectropion and a puckered condition 
of the mouth. We may also find cracking about the 
joints and moisture in these regions. Furuncles, bullae, 
or pustules may complicate matters. The hair may 
be shed from all parts and the nails become raised from 
their beds and shed. The mucous membranes participate 
in the disturbance, the tongue becomes markedly red, 
the lips cracked, and the nasal secretions increased. 
With the ectropion there is conjunctivitis. 



DERMATITIS EXFOLIATIVA 171 

The disease begins in some cases with a chill, followed 
by a fever that may rise to 104° F. Fever is present in 
all cases during the early period, and may continue 
throughout. It is sometimes continuous, with evening 
exacerbations; at other times it is only at night. Diar- 
rhea often is met with, and there may be vomiting, 
albuminuria, and pulmonary congestion. The patient 
complains of a feeling of chilliness and of pain, tender- 
ness, stinging, burning, or tingling of the skin. There 
may or may not be itching. The sensibility of the skin 
is preserved and the secretion of sweat may be normal, 
or lessened, or increased. The duration is very variable. 
Recovery may take place in six months or a year. In 
such cases relapses are the rule. Usually the course is 
chronic, the patient dying either in a few months or 
after years, by a gradual marasmus, though the end is 
usually hastened by pulmonary complications. 

Cases of localized dermatitis exfoliativa have been 
reported but they are rare. The tendency is for the 
disease to become general, though it may take years to 
do so. Cases of a recurrent type have been met with. 

Etiology. — We know very little about the causes of 
the disease. It is a disease of adults, and is more com- 
mon in men than in women. It may occur in children. 
It has been thought to be predisposed to by alcoholism, 
gout, and rheumatism. An attempt has been made to 
trace a relationship between it and general tuberculosis. 
There may be a history of scaling skin diseases in the 
family. Crocker inclined to the belief that a bacillus or 
its toxin will be found as the cause of the disease. At 
present we cannot speak with any certainty as to its 
etiology. 

2. Secondary Dermatitis Exfoliativa. — A condition of the 
skin exactly resembling the primary form is seen from 
time to time to follow upon or develop from a psoriasis, 
eczema, pemphigus foliaceus, and lichen ruber acuminatus 
or planus. The too vigorous use of chrysarobin or some 
other drug has been known to be followed by it. These 



172 DISEASES OF THE SKIN 

cases differ from the primary form only in their ante- 
cedent skin disease. Once developed they run the same 
course as the primary form, either becoming well quickly 
or falling into a chronic state from which recovery may 
or may not take place. The prognosis is, however, 
much better in the secondary than in the primary form, 
recovery after two or three months being frequent. 

Crocker states that the disease may occur in children, 
though it is very rare. In them it runs a more acute 
course and is attended by severe constitutional symptoms. 
It is usually of the secondary variety. 

Pathology. — Histological examination shows that the 
disease is a dermatitis, quite superficial at first, but when 
it has lasted some time the whole depth of the skin is 
involved and eventually there is new connective-tissue 
formation, which subsequently undergoes cicatricial 
contraction, with abundant pigmentation, hyperplasia 
of the elastic fiber bundles, and obliteration of the skin 
appendages (Crocker) . 

Diagnosis. — When the features of the disease, as laid 
down in the definition, are remembered, there should be 
no difficulty in recognizing it. No other disease involves 
the whole surface in a uniform dry and scaling redness. 
It differs from psoriasis in being universal, in an entire 
absence of thick, silver-white scales, and in leaving a 
smooth red surface when its papery scales are removed. 
Should it be secondary to a psoriasis, there will be no 
difficulty in obtaining a history of that disease. It differs 
from eczema in being a dry disease, with little infiltration, 
in its large papery scales, and in itching but slightly. 
Eczema may be almost universal, but some places are apt 
to be spared; there is always moisture of a sticky sort 
present somewhere or a history of the same; its scales 
are small and its itching intense. It differs from pem- 
phigus foliaceus in an absence of flaccid bullae. It differs 
from lichen in an entire absence of papules and in the 
whole course of the disease. All these diseases may be 
general, but it is exceedingly rare for them to become 



DERMATITIS EXFOLIATIVA 173 

universal, and it is always possible to obtain a history 
of their having been present at some time in a case of 
secondary dermatitis exfoliativa. It is hardly likely 
that scarlatina could be confounded with dermatitis. 
A few days' watching would in any event decide the 
question. 

Treatment. — The results of treatment of this disease 
leave much to be desired. Many internal and external 
remedies have been tried, but they all are of very uncer- 
tain value. There is no doubt that the patient is most 
comfortable when the skin is well oiled, and vaselin of 
good quality or pure olive oil answers well for this purpose. 
The general health is to be watched over, iron and quinin 
administered, and care exercised to preserve the strength 
by judicious feeding without stimulation. W. H. Mook 1 
found quinin given in large doses up to producing cincho- 
nism, that is from 40 to SO grains (3 to 5 grams) daily, 
cured some cases in from two to four months, and his 
observation has been confirmed by others. It should 
be tried in all cases. Diuretics may be given with the 
idea of relieving the congestion of the skin. Carbolic 
acid has been recommended, but in my hands proved 
worse than useless in one case. Pilocarpin, or jaborandi, 
is recommended by Hardaway in acute cases. Arsenic 
should not be given until late in the disease, if at all. 
Crocker recommended enveloping the body in calamin 
lotion, and giving bicarbonate of potassium every four 
hours in 20 grain doses, with 12 grains of citric acid and 
3 to 5 grains of quinin, the whole taken w T hile effervescing ; 
and the giving of quinin in acute febrile cases. Sherwell 
has reported several cases cured by the continuous use 
of linseed oil, both internally and externally. The patient 
is to chew or take in milk several ounces of flaxseed in 
twenty-four hours. He is to be kept in bed with a rubber 
sheet under him, and to be saturated, as it were, in crude 
linseed oil. If the oil is not used abundantly, it is worse 

1 Jour. Cut an. Dis., 1908, xxvi, 408. 



174 DISEASES OF THE SKIN 

than useless. This plan of treatment worked admirably 
in one of our cases. C. J. White 1 reports excellent results 
from keeping the patient constantly covered with borated 
talcum powder, freely used. Thyroid extract has proved 
helpful in some cases. In one of ours it aggravated the 
disease, and the patient made a good recovery after it was 
stopped, and she was treated with vaselin, soda baths, and 
careful feeding. 

In the primary form, or pityraisis rubra, treatment 
usually only alleviates the sufferings of the patient, but 
does not cure the disease. 

Prognosis. — In those cases secondary to psoriasis, 
eczema, etc., the prognosis is good, but should be guarded. 
In the primary cases the outlook is very grave, the 
mortality being high. 

Dermatitis Exfoliativa Epidemica. — Under this name 
Savill 2 has reported the occurrence, in Paddington 
Infirmary, of a number of cases of an apparently contagious 
disease of the skin, that began either as a discrete papular 
eruption, or as erythematous blotches like erythema nodo- 
sum or papulosum, or as small, flat papules enlarging 
at the periphery and spreading like ringworm. This 
stage lasted three to eight days. It was followed by the 
second stage, which was one of exudation or desquama- 
tion, and lasted three to eight weeks. However the 
disease began, the lesions soon ran together and formed 
a crimson surface of thickened and indurated skin, 
continually shedding its cuticle in scales or flakes of 
various sizes, sometimes mingled with drier exudation. 
In the second stage it assumed either a moist type, 
like eczema madidans, or a dry one like pityriasis rubra. 
About two-thirds of the cases were of the moist variety, 
and almost all at some period showed slight moisture, 
either in the flexures of the joints or behind the ears. 
Continuous exfoliation was present in all the cases. 
The third stage was one of subsidence. By degrees the 

1 Jour. Cutan. Dis., 1912, p. 705. 

2 British Jour. Dermat., 1892, iv, 35. 



DERMATITIS EXFOLIATIVA NEONATORUM 175 

inflammation lessened, leaving an indurated, thickened 
skin, with polished brown appearance, which was some- 
times raw, or parchment-like, smooth and shining, or 
cracked, or purpuric, especially in aged people. 

The disease began most often in the skin folds of the 
face and upper extremities; and involved either the whole 
body or limited areas. It generally spread by continuity. 
The hair and nails were all shed. 

The constitutional symptoms were anorexia and pros- 
tration. There was either no change in the body tem- 
perature or a slight rise in the evening during the height 
of the disease. Itching and burning were marked, and 
there was considerable suffering experienced in those 
cases in which the epidermis was shed. Relapses were 
frequent. Albuminuria was found in half of the cases, 
and death occurred in about 12.8 per cent, of the cases. 

More men than women were attacked and advanced 
age predisposed to it. A specific microorganism is thought 
to have been found in it. 

Clinically these cases resemble dermatitis exfoliativa, 
an instance of the apparent contagion of which we have 
met with. Its proper place has not been determined 
as yet. 

The treatment of the disease was by antiparasitic 
remedies, but was not very satisfactory. Painting an 
early patch with tincture of iodin seems to have cured 
it in some cases. 

Dermatitis Exfoliativa Neonatorum, also called Ritter's 
Disease and Keratolysis Neonatorum, is a disease of 
newborn children, first described by Ritter von Ritter- 
shain, 1 and said by him to be quite often seen in the 
foundling asylums of Prague. 

Symptoms. — It begins most often at the mouth as an 
erythema, and thence spreads to the trunk and extremities. 
Then the epidermis raises itself from the cutis, rumples, 
and spontaneously exfoliates in large folds, leaving a dry 

1 Arch. f. Kinderheilkunde, 1880, i, 53. 



17(3 DISEASES OF THE SKIN 

skin, or there may be exudation under the epidermis. It 
may originate anywhere on the skin. The mucous 
membranes may be involved. It begins usually between 
the second and fifth week of life, and lasts seven or eight 
days. Its course may be prolonged by relapses. There 
is no fever nor digestive disturbances. Furuncles, 
abscesses, or phlegmonous infiltration, with gangrenous 
destruction, may follow. Recovery takes place in about 
half the cases. It is supposed to be a pyemic condition 
of the skin and probably contagious. 

Treatment. — Special attention must be given to the 
nourishment of the child, and the maintenance of its 
body temperature. Alkaline lotions will prove beneficial 
in the early stage. Later a protecting ointment, such as 
that of oxide of zinc, or simple vaselin, or sweet oil, 
containing J to 1 per cent, of boric acid, followed by 
corn starch, will be indicated. 

Dermatitis Factitia. — It is a good rule to consider the 
possibility of malingering whenever we meet with an 
eruption that does not correspond to any recognized 
type, and at the same time is not due to the action of 
drugs known to have been ingested or locally applied, 
nor to irritants that have come accidentally in contact 
with the skin. Eruptions are feigned mainly by three 
classes of individuals, namely, soldiers, sailors, or con- 
victs for the purpose of shirking work; paupers for 
the purpose of gaining admission to hospitals; and 
hysterical young women for the purpose of exciting 
sympathy. Not only are feigned eruptions peculiar in 
appearance, but also it will be observed that they are 
usually on the left side of the body, as they are commonly 
due to acids applied by the right hand; or on the legs. 
The back is seldom the seat of these lesions. Most 
commonly they are irritative lesions, such as would be 
due to tartar emetic ointment, croton oil, nitric acid, 
carbolic acid, mustard, and the like. If made by acids, 
the lesions will often have lines radiating from the main 



DERMATITIS GANGRENOSA 177 

mass showing where the acid has run further than in- 
tended. The sharp, more or less square outline is another 
characteristic of these lesions. Some of the lesions 
imitate genuine disease with amazing faithfulness. 

It is impossible here to give a full account of the 
feigned eruptions. A good list is given by Van Harlingen, 1 
and to this I would refer the reader. Sycosis by tartar 
emetic ointment and tar; favus by means of acids; 
alopecia areata by means of plucking the hair; ringworm 
by means of depilatories; scabies by means of excoriating 
with a fine needle; various forms of ulcers, vesicular 
and pustular eruptions by means of acids and caustics; 
gangrene in the same way; all these and others have been 
simulated. In case of a suspected feigned eruption the 
part should be covered with an impermeable dressing, 
when, of course, the lesions will soon be well. 

Dermatitis Gangrenosa or Sphaceloderma. — Gangrene 
of the skin may be due to a great variety of causes. 
Many cases are due to purely local causes, such as burns, 
bruises, compression, chemical action, and the like. It 
is seen in the course of diabetes, albuminuria, and some 
cardiac diseases; with degenerative changes taking place 
in the vascular walls of arteries, or plugging of their 
lumen; and in connection with other skin diseases, 
as carbuncle. Besides these we have a group of little- 
understood cases of gangrene, due apparently to nervous 
influences, and occurring in connection with diseases of 
the nervous system. These may occur anywhere, and 
may be superficial or deep. They behave like surgical 
gangrene, and are to be treated on the same principles. 
Other cases have been reported as following upon some 
slight injury, such as running a needle into a finger. 
The lesions run up the arm or leg in the form of papules 
that soon change into flaccid vesicles, which rapidly 
crust and form an eschar. When the crust falls a depressed 

1 Morrow's System of Gen.-Urin. Dis., Svph., and Dermat., vol. iii, 
New York, 1894. 

12 



178 DISEASES OF THE SKIN 

cicatrix is left. The process tends to last a long time, 
with many relapses. It is always to be borne in mind 
that gangrene occurring in hysterical women is apt to be 
self-imposed. If such cases are carefully noted, it will 
be observed that the spots appear where they can be 
reached most readily by the patient's right hand, or 
left, if she be left-handed. 

Treatment. — In all these forms of gangrene attention 
must be given to the general health of the patient and the 
lesions must be treated on general antiseptic principles. 

There are two forms of cutaneous gangrene that have 
received special names that must be noticed here. They 
are: (1) Symmetrical gangrene, or Raynaud's disease; 
and, (2) Dermatitis gangrenosa infantum. 

1. Symmetrical Gangrene.— This was first described by 
Maurice Raynaud, 1 and since then has been observed by 
others, although it is a rare disease. It most often attacks 
the second and third phalanges of the fingers and toes, 
next most frequently the nose and ears; but any part 
may be affected-. The parts become pale or blue, cold 
and hard, and then swell. They feel numb, but the 
patient may experience darting or stabbing pains in 
them. If pricked, no blood escapes. The process may 
stop here and the parts may return to their normal 
state; or after a time, hours or weeks, they become black, 
a line of demarcation forms, and separation of the affected 
part takes place. The process may stop short of the 
complete destruction of the part and recovery may 
take place, though relapses are liable to occur. It may 
result simply in a peculiar induration and thinning of the 
fingers. The disease is symmetrical. It may involve 
all four extremities, but usually only two are affected. 
Bullae may form. The nails may fall. Occurring on 
other parts of the body localized patches show the same 
symptoms as those on the hands and feet. 

i Th&se do Paris, 1872, 



DERMATITIS GANGRENOSA 179 

Etiology. — Men are more often affected than women. 
People of all ages are liable to it. Exposure to cold 
seems to be a causative factor, and not a few of its victims 
have been subject to chilblains or other symptoms of 
poor circulation. The malarial, the syphilitic, or other 
cachexias and the gouty habit have been supposed to be 
predisposing causes. It has followed various dermatoses. 
It is probably of neurotic origin, and due to a contraction 
of the arterioles. 

Treatment. — The internal treatment that has done 
best has been the administration of quinin and bella- 
donna. Amyl nitrite and nitroglycerin may be given. 
Locally, galvanism has done good. Stimulation by means 
of lotions of various kinds may be tried. Cold applica- 
tions are said to be better than hot. If gangrene has 
occurred it must be treated on surgical principles. 

Prognosis. — The outlook is not good. Death may 
result in those who are not robust. Even if one attack 
is recovered from, another is apt to occur. 

2. Dermatitis Gangrenosa Infantum (Crocker). — Syno- 
nyms: Varicella gangrenosa (Hutchinson); Pemphigus 
grangrenosus (Stokes) ; Rupia escharotica (Fagge) ; 
Ecthyma infantile gangreneux (Pineau); Gangrenes 
multiples cachectiques de la peau; Ecthyma terebrant 
de l'enfance (Baudouin). 

Under these names has been described a disease of the 
skin that occurs most often after varicella, but may occur 
after other diseases of the skin in children, such as variola, 
vaccinia, purpura, erythema nodosum. It consists 
essentially in the formation of deep or superficial round 
or oval ulcerations beneath a black slough, following 
upon a varicella or other pustule. The lesion when fully 
formed may be one inch or more in diameter, and three- 
quarters of an inch deep. The wider the slough, the deeper 
is the ulcer. Around the slough is a red areola. Crocker 
says that if the gangrene occurs while varicella is still 
present, it begins on the head or upper part of the body, 
and then looks like a vaccination pustule; while if it 



180 DISEASES OF THE SKIN 

begins late in the course of the disease, the lesions will 
be located on the lower half of the body, especially on 
the buttocks and thighs. In the latter case the affected 
parts are riddled with ulcers of all sizes, shapes, and 
depths. If several ulcers run together, very large and 
irregular ones may form. If the lesions are extensive 
or numerous, they may cause death, very frequently 
by pulmonary complications. 

Etiology. — Infants and young children under three 
years of age are those affected by this disease, and most 
of them are girls. Debilitating diseases, predispose to 
the disease. In infants' hospitals cases of this sort occa- 
sionally occur in epidemics of varicella. It may occur 
independently of varicella. The disease seems to be a 
product of several dyscrasic conditions plus a microbic 
infection, several varieties of microorganisms having been 
found in connection with it. 

Treatment. — The cases are to be managed upon 
general principles. Tonics, fresh air, good food, and 
hygienic surroundings, and remedies addressed as far as 
may be to the underlying constitutional condition are the 
best means for combating the disease. Crocker recom- 
mends quinin and sulphocarbonate of sodium, 5 grains 
(0.33) every three hours, and the injection of 2 or 3 drops 
of a 2 to 3 per cent, solution of carbolic acid in several 
places about the patch, and wet boric acid lotions. Iodo- 
form, aristol, and antiseptic dressings are indicated. 

Prognosis. — The prognosis is not good in extensive 
cases. Death is apt to result from lung complications or 
pyemic infection. 

Dermatitis Herpetiformis. — Synonyms: Hydroa of Bazin 
and Tilbury Fox; Herpes phlyctenodes of Gilbert; Herpes 
gestationis of Bulkley; Pemphigus pruriginosus and circi- 
natus; Pemphigus a petites bulle, Hydroa bulleux, Herpes 
circinatus of Wilson; Dermatite polymorphe of Brocq. 

This name was first suggested by Duhring, 1 of Phila- 

1 Jour. Amer. Med. Assoc, 1884. iii, 225. 



DERMATITIS HERPETIFORMIS 181 

delphia, for a disease which is characterized by great 
multiformity and marked grouping of the lesions; by 
pruritus of varying intensity; by chronicity of course; 
and by a strong tendency to relapse. 

Symptoms. — In severe cases there may be prodromas 
for several days preceding the outbreak, such as malaise, 
constipation, fever, chills, sensations of heat or cold, or 
these alternating, and itching. In mild cases these are 
absent. The onset of the disease may be gradual or 
sudden — the latter not infrequently. The eruption may 
be diffused over the greater part of the general surface, 
or it may be in localized patches. Favorite sites for it 
are the extensor aspects of the limbs, sacral region, and 
over the scapulse, but the disease has not such marked 
sites of preference as some other diseases exhibit. Itching 
and burning, which are severe, precede or accompany the 
outbreak. It may begin as an erythematous, vesicular, 
bullous, pustular, or papular eruption, or by a com- 
bination of two or more of these, the multiformity being 
a characteristic, excepting in children. It shows a 
tendency for one variety of lesions to pass over into 
another, either during the attack or at some relapse. 
Grouping of the lesions is a marked characteristic of the 
disease. The relapses occur at intervals of weeks or 
months. All regions are invaded, the course is essen- 
tially chronic, and in pronounced old cases the skin 
is excoriated and pigmented. The mucous membranes 
may be involved. 

Dermatitis Herpetiformis Erythematosa. — This form is 
usually of urticarial or erythema multiforme type, and 
occurs either in patches or diffused. The circumscribed 
patches may coalesce and form larger patches with 
marginate outline. The color varies with the age of the 
lesion, becoming darker with age. There may be maculo- 
papules, flat infiltrations, or vesicopapules. It may con- 
tinue in this way for days or weeks, but usually it changes 
to the multiform type. There is pruritus. 



182 



DISEASES OF THE SKIN 



Dermatitis Herpetiformis Vesiculosa. — This is the form 
most usually met with. The vesicles are from pinhead 
to pea-sized, flat or raised, irregular or stellate in shape, 
glistening, pale yellow or pearly, firm, tensely distended, 
and without areola. There may be papules, papulo- 
vesicles, vesicopustules, and sometimes bullae. The 
lesions are disseminated, but aggregated into clusters of 
two, three, or more, or may form groups as large as a 
silver dollar. If the vesicles are near together, they tend 

Fig. 22 




Dermatitis herpetiformis 



to run together and form blebs, which are raised and 
surrounded by a pale or distinct red areola, and of a 
puckered or drawn-up appearance. The eruption is 
usually profuse. All regions are affected. Severe itching 
and sometimes burning last until the vesicles are broken, 
which may not be for several days. Sometimes there is 
a good deal of constitutional disturbance. This is T. 
Fox's hydroa herpetiforme. 

Dermatitis Herpetiformis Bullosa. — In this form we 
have more or less typical bulla? filled with cloudy or serous 

1 By the courtesy of Dr. S. D. Hubbard. 



DERMA TIT IS HERPETIFORMIS 



183 



fluid, from pea- to cherry-sized, irregular or angular in 
outline, and with or without an inflammatory base. They 
occur in groups, with red and puckered skin between, and 



Fig. 23 




Hand of a person affected with dermatitis herpetiformis. 1 

more or less vesicles and pustules, disseminated over the 
skin. All parts of the body are affected. They come 
out in crops at intervals, rupture in two or three days, 
and crust over. This is T. Fox's hydroa bulleux. 

'From a replica of Baretta's model, No. 1333, in the Museum of the 
St. Louis Hospital, Paris. 



184 DISEASES OF THE SKIN 

Dermatitis Herpetiformis Pustulosa. — This form is less 
clearly defined than the vesicular form, because vesicles, 
vesicopustules, and bullae often occur at the same time. 
It may occur uncomplicated and be pustular throughout. 
The pustules are acuminated, round or flat, tense or 
flaccid, and vary in size from a pinpoint to a twenty- 
five-cent piece. The large pustules generally have an 
areola. They tend to flatten, spread, and dry in the 
centre, and to group. On the trunk we may find a central 
pustule surrounded by a variable number of small 
pustules. They are opaque, and whitish or yellowish. 
There may be slight hemorrhagic exudation into them. 
They are slow of development, an attack lasting from 
two to four weeks. There is more marked constitutional 
disturbance than in the other forms. It is accompanied 
by heat, pricking, and itching. It sometimes precedes, 
follows, or alternates with the other forms. 

Dermatitis Herpetiformis Papulosa. — This is the rarest 
and mildest variety of all, and consists in small or large, 
irregularly shaped, firm, reddish or violaceous papules in 
disseminated groups, the papules being usually excoriated 
on account of the scratching to relieve the severe itching. 
Ill-defined papulovesicles are also present. 

Dermatitis herpetiformis multiforme is simply a combina- 
tion of all the preceding varieties, with the type changing 
from time to time. Pigmentation is a feature of this 
variety as well as of all the others, and occurs after the 
disease has lasted for some years. 

Etiology. — The disease occurs in both sexes, and is 
supposed to be a trophoneurosis. It occurs at all ages, 
but most commonly between thirty and sixty years of age. 
Our oldest patient was a woman of eighty-two. It has 
been met with in children three and four years of age. 
Little is known as to its causes. It occurs quite indepen- 
dently of pregnancy, and in one case became better 
during the same. Another case was aggravated during 
pregnancy, and by irregular menstruation. One case 
seemed to arise from a nervous shock. Most cases are 



DERMATITIS HERPETIFORMIS 185 

seen in the subjects of nervous exhaustion of various 
kinds. By Bazin the gouty diathesis was considered to 
be a predisposing cause of hydroa, and hence possibly 
of dermatitis herpetiformis. Winfield has reported 
four cases in which sugar was found in the urine. Oc- 
casionally septicemia may stand in causal relation to 
the disease as also auto-intoxication from the intestinal 
tract. 

Pathology. — A careful study of herpetiform hydroa 
has been made by G. T. Elliott. 1 This is considered by 
Duhring as one variety of the disease under consideration. 
He showed that the vesicles originate in the epithelium 
of the sweat ducts, several being implicated at the same 
time, and that the ordinary signs of inflammation are 
present. He believes that the inflammation is secondary, 
and is seated in the papillary layer of the corium. De- 
generated nerve fibers are found, and the disease is 
believed to be due to trophic nerve disturbance. Laredde 
and Perrin 2 are of the opinion that eosinophile cells are 
closely related to the process of bullous formation, and 
that there is a vasomotor paralysis allowing of the escape 
of bloody or lymphatic serum into the connective tissue 
and the formation of bullse. They raise the question of a 
possible relation between renal action and the escape of 
eosinophile cells. T. C. Gilchrist's 3 studies show that in 
the early stages the vesicles are formed beneath the 
epidermis on account of an inflammatory process going 
on in the corium. He also notes the presence of the 
eosinophile cells. 

Diagnosis. — This disease must be differentiated from 
erythema multiforme, eczema, and pemphigus. It 
differs from erythema multiforme in not occurring markedly 
upon the backs of the hands, wrists, forearms, and feet; 
in its more intense itching, instead of the burning of 
erythema; in its chronicity and greater tendency to 

1 New York Med. Jour., 1887, xlv, 449. 

2 Ann. de derm, et d. syph., 1895, vi, 281. 

3 Johns Hopkins Hosp. Rep., vol. i. 



186 DISEASES OF THE SKIN 

relapse; and in its obstinacy to treatment. If the case is 
watched for a time, the character of the eruption will 
be seen to change. 

The vesicular form of dermatitis herpetiformis differs 
from vesicular eczema in having larger vesicles of angular 
or stellate outline, and with no disposition to rupture, 
and to run together to form patches; in the grouping 
of these vesicles in small clusters; in its herpetic character; 
more intense itching; greater constitutional disturbance; 
and greater obstinacy to treatment. 

The papular form differs from papular eczema in the 
irregularity of the size and form of the papules; their 
strong disposition to group and not to coalesce; their 
slow evolution; their appearance in crops with free 
intervals; the chronicity of its course; and obstinacy 
to treatment. 

It differs from herpes iris in being a general eruption, 
and in not having the groups of vesicles arranged in 
circles about a central vesicle. 

It differs from pemphigus in the grouping of its lesions, 
which are smaller than those of pemphigus; in their more 
inflammatory, herpetic aspect, in its intense pruritus, 
and in the occurrence of vesicles and pustules at the 
same time with the bullae. If only bullae are present, 
the diagnosis is difficult. 

Impetigo herpetiformis is always and only pustular, and 
never has erythematous patches, vesicles, or bullae. It 
develops by new lesions springing up in a circular manner 
about the old ones. It is unattended by pruritus, and is 
a grave disease, often ending fatally. 

Papular urticaria lacks the grouping of herpetiform 
dermatitis, prefers the extensor aspects of the limbs, 
and presents wheals. 

A well-marked case of dermatitis herpetiformis with 
erythematous patches, grouped vesicles, pustules, and 
bullae of stellate form, intensely pruritic and with a 
myriad of excoriations, is so characteristic as to admit 
of no doubt in diagnosis. 



DERMATITIS HERPETIFORMIS 187 

Treatment. — This disease is one of the most rebellious 
to treatment. Hygienic measures, fresh air, proper and 
restricted diet, no meat being allowed in some cases, 
abstinence from all alcoholics, and relief from all nervous 
disturbances must be secured as far as may be. Nerve 
tonics may be given, such as arsenic, strychnin, cod-liver 
oil, hypophosphites, and quinin; alkaline diuretics, 
belladonna in full doses, laxatives, all may be tried. 
Phenacetin, 5 to 10 grains (0.33 to 0.66), three times a 
day, has done well in some cases. Antipyrin exerts a 
more powerful influence, but is not so safe. 

Locally Duhring has found the best treatment to be 
sulphur ointment containing two drachms (8) of sulphur to 
the ounce (32), well rubbed in with vigorous friction as 
in scabies. The frictions should be continued for an hour 
at a time. This plan is not suitable for the erythematous 
variety, and in some other forms cannot be used. The 
spinal douche acts favorably in some cases. Other 
authorities recommend alkaline and bran baths, dusting 
on starch powder, with oxide of zinc, Lassar's paste, 
resorcin ointment or lotion 1 to 5 per cent., liquor carbonis 
detergens in water, 3ij (16) to 5 y iij (250); calamin 
lotion, liquor picis alkalinus, tar ointment, ichthyol, 2 to 
10 per cent, aqueous solutions, solutions of carbolic acid, 
3j (4) to 5j (32), dabbed on. Guaiacol, 5 per cent, 
in ointment base, and camphor and chloral, 1 to 5 per 
cent., combined in ointment or lotion, control the itching. 
Schamberg recommends the mercurial vapor lamp. All 
these will afford a certain measure of relief, but the disease 
is apt to laugh at our efforts to drive it away. 

Prognosis. — The duration of the disease is indefinite. 
Some mild cases may recover in a short time, never to 
relapse. The course of the disease is essentially chronic; 
it may last for many years; it shows a strong tendency to 
relapse at longer or shorter intervals; and, as a rule, does 
not materially affect the patient's health. Old people and 
those not otherwise in good health may be worn out by 
the itching and the discomforts of the disease. 



188 DISEASES OF THE SKIN 

Dermatitis, Malignant Papillary. — See Paget's Disease of 
the nipple. 

Dermatitis Medicamentosa. — By this is meant inflamma- 
tion of the skin due to the systemic ingestion of drugs. 
There are a great number of drugs that may cause erup- 
tions upon the skin in susceptible individuals. These 
effects are seen but rarely with some drugs, and quite 
constantly with others. The modus operandi of drugs 
in producing eruptions is probably not the same in all 
cases. Some, doubtless, act by irritating the skin while 
circulating in the blood; some while being excreted by 
the glandular apparatus; while many of them do so by 
direct or reflex excitation of the vasomotor nerves. 
Idiosyncrasy is marked in all of them. Deficient elimina- 
tion by the kidneys is a contributive factor in many 
cases. Erythema is the principal feature of nearly all 
drug eruptions, to which may be added vesiculation or 
pustulation. Two drugs, bromin and iodin, produce 
pustular eruptions in nearly all cases when ingested. 
Most drug eruptions appear with more or less suddenness, 
and disappear quite promptly when the drug is stopped. 
They are symmetrical and general in distribution as a 
rule. They may be universal or localized, and the extent 
of the eruption is in no way proportioned to the dose. 
The cause of all doubtful eruptions of an erythematous 
type should always be sought for in the ingestion of 
some drug. As a rule, little, if any, treatment is required 
for this form of dermatitis apart from stopping the drug. 
Sometimes the system becomes accustomed to a drug, 
and does not react unfavorably to it if its administration 
is persisted in. With most drugs this is not the case. 

The subject of drug eruptions is so large a one that 
here no more than a skeleton account can be given. 

A most useful classification of drug eruptions according 
to lesions is given by Stelwagon, 1 as follows: 

1 Diseases of the Skin, Philadelphia, 1914. 



DERMATITIS MEDICAMENTOSA 189 

Alopecia. — Boric acid and thallium acetate. 

Bullous. — Aconite, anacardium, antipyrin, boric acid, 
bromin, chloral, copaiba, cubebs, iodin compounds, 
iodoform, mercury, opium, phosphoric acid, quinin, and 
salicylates. 

Carbuncular (Anthacoid). — Arsenic, bromin compounds, 
chloral, iodin, and opium. 

Cyanotic. — Acetanilid and potassium chlorate. 

Eczematons. — Belladonna, boric acid, carbolic acid, 
morphin, opium, and sodium borate. 

Erysipelatous. — Arsenic, belladonna, conium, digitalis, 
ipecac, quinin, and stramonium. 

Erythematous. — Acetanilid, alcohol, antipyrin, antitoxin, 
arsenic, belladonna, benzoic acid, boric acid, bromin com- 
pounds, cantharides, capsicum, carbolic acid, castor oil, 
chinolin, chloral, chloralamid, chloroform, conium, copaiba, 
cubebs, dulcamara, exalgin, guaiacum, gurjun oil, hydro- 
cyanic acid, hyoscyamus, iodoform, lead acetate, mer- 
cury, opium, phenacetin, phosphoric acid, pilocarpin, 
piper methysticum, potassium chlorate, quinin, salicyl- 
ates, santonin, sodium benzoate and borate, stramonium, 
sulphonal, tannic acid, tar, turpentine oil, tuberculin, 
and veratrum viride. 

Erythematopapular. — Acetanilid, antipyrin, benzoic acid, 
copaiba, digitalis, gurjun oil, iodin compounds, iodoform, 
phenacetin, silver nitrate, and potassium chlorate. 

Epitheliomatous . — Arsenic, secondarily to keratoses. 

Furuncular. — Antipyrin, arsenic, bromin compounds, 
calx sulphurata, chloral, condurango, ergot, mercury, 
and opium. 

Gangrenous. — Arsenic, belladonna, ergot, iodin com- 
pounds, quinin, and salicylates. 

Herpetic. — Arsenic, belladonna, iodin compounds, mer- 
cury, and salicylates. 

Keratotic. — Arsenic. 

Morbilliform. — Antipyrin, antitoxin, belladonna, boric 
acid, copaiba, cubebs, opium, sodium borate, sulphonal, 
tar, turpentine, and tuberculin. 



190 DISEASES OF THE SKIN 

Nodular. — Bromin and iodin compounds. 

Papillomatous. — Bromin and iodin compounds. 

Papular. — Arsenic, boric acid, bromin compounds, can- 
tharides, chloral, conium, copaiba, cubebs, digitalis, 
iodin compounds, jaborandi, mercury, opium, terebene, 
and turpentine oil. 

Papulovesicular. — C apsicum . 

Pigmentary. — Arsenic, antipyrin, and silver nitrate. 

Pruritus. — Chloral, copaiba, opium, and strychnin. 

Purpuric. — Antipyrin, antitoxin, arsenic, benzoic acid, 
calx sulphurata, chloroform, copaiba, cubebs, ergot, 
hyoscyamus, iodin compounds, iodoform, lead acetate, 
mercury, phosphoric acid, potassium chlorate, oil of sandal- 
wood, quinin, salicylates, stramonium, and sul phonal. 

Polymorphous, resembling erythema multiforme. Anti- 
pyrin, antitoxin, boric acid, chloral, copaiba, cubebs, 
coal-tar derivatives, exalgin, iodin compounds, iodoform, 
opium, and potassium chlorate. 

Psoriasiform. — Sodium borate and tuberculin. 

Pustular. — Aconite, antimony, antipyrin, arsenic, bro- 
min compounds, calx sulphurata, cod-liver oil, con- 
durango, ergot, hyoscyamus, iodin compounds, mercury, 
nitric acid, opium, salicylates, tanacetum, turpentine 
oil, and veratrum viride. 

Scarlatiniform. — Antipyrin, antitoxin, belladonna, 
chloral, copaiba, cubebs, digitalis, hyoscyamus, mercury, 
nux vomica, opiates, pilocarpin, rhubarb, quinin, salicy- 
lates, stramonium, strychnin, sulphonal, turpentine oil, 
tuberculin, and viburnum prunifolium. 

Ulcerative. — Arsenic, bromin compounds, chloral, iodin 
compounds, and mercury. 

Urticarial. — Alcohol, anacardium, antimony, antipyrin, 
antitoxin, arsenic, benzoic acid, bromin compounds, 
chloral, copaiba, cubebs, digitalis, dulcamara, guarana, 
hydrocyanic acid, hyoscyamus, iodin compounds, mer- 
cury, opium, phenacetin, pilocarpin, pimpinella, quinin, 
salicylates, salol, sodium benzoate, tannin, tar, turpentine 
oil, and valerian, 



DERMATITIS MEDICAMENTOSA 191 

Vesicular. — Aconite, anacardium, antimony, antipyrin, 
arsenic, bromin compounds, calx sulphurata, cannabis 
indica, chloral, copaiba, cubebs, cod-liver oil, ergot, 
iodin compounds, iodoform, nux vomica, quinin, sali- 
cylates, sodium santonate, and turpentine oil. 

V esicopustular . — Antimony and antipyrin. 

Some of the drugs causing eruptions are: 

Acids: Benzoic acid and its compounds may produce 
an eruption of urticaria, maculopapules, or erythema. 
Boric acid and its compounds may cause an erythematous, 
psoriatic, or erythematobullous eruption. The psoriatic 
form is unusual. Carbolic acid causes an erythema that 
may be scarlatinous in character. Nitric acid, in rare 
cases, gives rise to a pustular eruption. Salicylic acid 
and salicylate of sodium produce erythematous, urticarial, 
vesicular, bullous, petechial, or purpuric manifestations. 
Tannic acid caused an erythema in one case. 

Acetanilid causes erythema; sometimes cyanosis. 

Aconite gives rise to itching, vesicular, pustular, or 
bullous lesions. 

Alcohol may cause a generalized erythema and urticaria. 

Amygdala amara causes erythema. 

Antifebrin may give rise to cyanosis. 

Antimony causes an urticarial or vesiculopustular 
eruption. 

Antipyrin gives rise to an erythema, consisting of small 
irregularly circular, slightly elevated patches, which 
may be discrete or confluent, and is at times followed 
by desquamation. Profuse sweating and itching may 
accompany it, and it affects the chest, abdomen, back, 
and extremities, especially their extensor surfaces. It 
may be measly in character or purpuric. It has given 
rise also to bullous, furuncular, and purpuric eruptions; 
herpes labialis; burning and necrosis of penis and scrotum. 
It may cause a bullous eruption of the mouth, beginning 
as a general or localized erythema. This eruption may 
occur with or without involvement of the skin. 

Antitoxin quite often causes an urticarial or multiform 



192 



DISEASES OF THE SKIN 



erythema. At times the eruption resembles scarlatina, 
and at other times measles. There are often fever and 
joint pains, and occasionally prostration. The eruption 
may not appear until several days after the administration 
of the toxin, and may last a week or more. 

Argentum nitras when used continuously may produce a 
grayish-black discoloration of the skin, or an erythemato- 
papular eruption. 

Fig. 24 




Bromide of potassium eruption in a child. 

Arsenic causes erythema of scarlatinal type, papules, 
petechias, urticaria, vesicles, pustules, zoster, and an 
erysipelatous eruption. Itching may attend some of 
these eruptions. Grayish or brownish discolorations of 
the skin have followed prolonged ingestion of the drug. 
Boils and carbuncles have also been produced, as well as 
thickening of the skin of the palms and soles, and that 
over the knuckles, either in the form of diffused keratosis 
or as numerous small corns. 

Belladonna or atropin produces a scarlatinal eruption 
with or without vesicles and pruritus. As the fauces are 
often reddened the resemblance to scarlatina is striking. 
It will clear up in twenty-four hours, and the eruption is 



DERMATITIS MEDICAMENTOSA 193 

patchy, not punctate. Moreover, there is none of the 
prodroma of scarlatina nor the strawberry tongue. The 
pupils may be dilated. 

Bromin in combination with potassium, ammonium, 
or other bases, produces the well-known "bromic 
acne" so commonly seen in the treatment of epilepsy 
It is an outbreak of dark-red inflammatory papules, 
papulopustules, and cutaneous abscesses that bear a 
close resemblance to acne, and, like it, often leave scars. 
It differs from acne in having a wider distribution and in 
occurring at all ages. This is the most common form of 
bromin eruption, but erythematous, urticarial, papular, 
ulcerative, verrucose, vesicular, and bullous eruptions 
have been met with. Rarer forms are papillary hyper- 
trophy, resembling condylomata, and large, irregular, 
elevated ulcers. The eruption may continue long after 
the administration of the drug has been stopped. It 
would be desirable to prevent these eruptions, but thus 
far there is nothing that will do so with certainty, except 
stopping the administration of the drug. Arsenic, sulphide 
of calcium, or aromatic spirits of ammonia may be tried, 
and diuresis maintained. 

Calx sulphurata gives rise to vesicles, pustules, and 
furuncles; rarely to petechise. 

Cannabis indica has caused a vesicular eruption. 

Cantharides gives rise to erythematous and papular 
lesions. 

Capsicum may cause erythematous and papulovesicu- 
lar lesions. 

Chinolin causes an erythema. 

Chloral produces erythematous, papular, urticarial, 
vesicular, and petechial eruptions. At times the chloral 
erythema bears a strong resemblance to scarlatina. 

Chloralamid causes a general punctate hyperemia with 
vesicular lesions with febrile reaction. 

Chloroform produces erythematous and purpuric 
lesions. 

Cinchona and quinin produce all the primary lesions 
13 



194 DISEASES OF THE SKIN 

of the skin, though most frequently an erythema of 
scarlatinal type, attended by congestion of the fauces 
and followed by desquamation. 

Condurango causes acne and furuncles. 

Conium causes an erysipelatous eruption as well as an 
erythematous one. 

Copaiba and cubebs. Their most common eruption is 
an erythema which is often of a scarlatinal type, but may 
resemble measles, and may be followed by desquamation. 
Outbreaks of wheals, vesicles, bullae, or petechia may 
occur. Pruritus may be present. The odor of the drug 
may usually be detected in the breath. 

Digitalis produces an erythema of an erysipelatous, 
papular, or urticarial character. 

Ergot, quite apart from the condition of ergotism, may 
cause vesicles, pustules, furuncles, and petechia. 

Guaiacum and gurjun oil cause eruptions like those of 
copaiba. 

Hydrargyrum gives rise to a scarlatiniform eruption, 
followed by desquamation, as well as urticaria, herpes, 
impetigo, purpura, furuncles, and ulcers. 

Hyoscyamus produces an itching erythematous erup- 
tion, with more or less edema and wheals. Purpura has 
also followed its use. 

Iodin and its compounds, like bromin, give rise to a 
pustular or papulo-pustular, acneiform eruption, usually 
upon the face, back, and upper part of the chest and 
arms; but often general. This is the most typical form 
of eruption, but an erythema limited to the face and 
chest or general, an urticaria, a vesicular erythema, an 
eczema-like eruption, a bullous form resembling pemphi- 
gus, as well as carbuncular, petechial/ and nodular erup- 
tions, may occur. Sometimes there will be more than 
one type present. It is supposed that iodic eruptions 
occur more often in cases in which the kidneys are more 
or less inactive. They sometimes follow the administra- 
tion of very small doses. It is thought that the iodide 
of sodium is less apt to cause cutaneous disturbances 



DERMATITIS MEDICAMENTOSA 195 

than are the other salts of iodin. At times the system 
becomes accustomed to the drug, or the kidneys acting 
more freely relieve the skin. The trouble may be relieved 
or, to a large extent, obviated by administering the salt 
largely diluted with vichy or seltzer water, or by giving 
it in milk. The free use of alkaline diuretics will relieve 
the skin. Arsenic has also been recommended, but does 
no better here than in the bromin eruptions. 

Iodoform is sometimes absorbed from surgical dressings, 
and gives rise to erythema, urticaria, and purpura. 

Ipecac in one case caused burning heat, with an ery- 
sipelatous eruption. 

Iron is said to produce an acne; also erythematous, 
vesicular, and urticarial eruptions. The iodide of iron is 
the form that usually produces these eruptions, and it 
is the iodin that causes them. 

Morphin may cause urticaria, ulcers, a papular, vesic- 
ular, or pustular eruption. 

Nux vomica may give rise to a scarlatina-like ery- 
thema and a miliary eruption. 

Oleum morrhufle may cause an eczematous eruption or 
an acne. 

Oleum ricini may cause an itching erythema. 

Oleum santali may cause a general petechial eruption. 

Opium causes itching and an erythema resembling- 
scarlatina or measles in character, which though often 
widely distributed, is not infrequently limited to certain 
regions. 

Phenacetin may cause a general erythematous eruption. 

Phosphorus causes bullous eruptions and also purpura. 

Pilocarpin, or jaborandi, after prolonged use, may 
cause umbilicated papules located in the sweat glands, 
especially on the face and limbs. These may be topped 
with vesicles or pustules. 

PLx liquida produces an erythema. 

Potassium chlorate has caused a papular erythema, 
while bluish spots on the skin, and a general cyanosis 
may occur after continuous use of the drug. 



196 DISEASES OF THE SKIN 

Quinin produces a scarlantiniform erythema, as well 
as urticarcial, purpuric, vesicular, and bullous eruptions. 

Rhubarb may cause a scarlatiniform erythema. 

Salipyrin has caused edema. 

Salol has caused urticaria. 

Santonin produces an urticarial or a vesicular eruption. 

Stramonium gives rise to an itching or burning scar- 
latinoid erythema, a petechial eruption, or an erysipela- 
tous inflammation. 

Strychnin may cause a scarlatiniform rash. 

Sulphonal produces a scarlatiniform erythema. 

Sulphur causes dark discoloration of the skin, and an 
eczematous, pustular, furuncular, or papular exanthem. 

Tannin may cause urticaria or erythema. 

Tansy has caused a varioliform eruption. 

Thallium acetate causes the hair to fall. 

Tuberculin and other serum injections may cause 
scarlatiniform or measles-like patches of erythema, as 
well as a psoriasiform eruption. 

Thiosinamin has caused erythema, swelling of face, 
and redness of fauces and mouth. 

Turpentine and terebene may cause scarlatiniform 
erythema and a papular and vesicular eruption. 

Veratrum viride gives rise to an erythematous 
eruption. 

Veronal has caused erythema, sometimes so profound 
as to be purpuric. 

Besides these, Hyde and Montgomery mention the 
following drugs as having produced eruptions: anacar- 
dium, benzol, chinolin, chloroform, cocain, creosote, 
duboisin, guarana, kava-kava, lactophenin, matico, pim- 
pinella, and plumbum. 

Treatment. — The treatment of all drug eruptions is 
the same, namely, stopping the use of the drug and 
giving alkaline diuretics. Locally, soothing remedies 
should be applied, such as cold cream, vaselin, and oxide 
of zinc ointment, or preferably alkaline lotions. 



DERMATITIS PAPILLARIS CAPILLITII 



197 



Dermatitis Papillaris Capillitii. — Synonyms: Dermatitis 
papillomatosa capillitii; Frambcesia; Sycosis frambcesia 
(Hebra); Sycosis capillitii (Rayer); Mycosis frambce- 
siodes, or Acne keloidique, or Pian ruboide (Albert); 
Acne keloid. 



Fig. 25 




Dermatitis capillitii. 



Symptoms. — This is one of the rare diseases of the 
skin. It begins as an eruption of small-sized papules 
upon the back of the neck at the margin of the hair. 
They are of the color of the skin, or slightly red with an 
inflammatory halo; exceedingly hard and firm; and 
when pricked they give vent to a little bloody serous 
fluid. Increasing slowly in number and crowding to- 
gether, they form raspberry-like elevations with uneven, 
lobulated surfaces. Gradually the disease spreads later- 
ally and also upward upon the hairy scalp, even reaching 
the vertex after months and years. After a time the 
masses may soften a little and contain pus. At times 
they secrete a foul-smelling fluid, and crust. Grad- 
ually they become sclerosed and keloidal. Pustules may 
form on the hairy scalp, and little tufts of hair protrude 
out of them. When they become keloidal they may be 
bald or tufted with hair. Hairs plucked from the growths 
are sometimes normal and sometimes atrophied. There 



198 DISEASES OF THE SKIN 

may be pain or tenderness, or there may he no subjec- 
tive symptoms. 

Etiology. — Men are more often affected than women. 
The disease may begin at any age. Negroes seem to be 
more subject to it than the white races. They are pecu- 
liarly prone to keloidal growths, and it is probable that 
the disease is a species of keloid starting in the follicles, 
such as is so frequently seen on the male negro face. The 
etiology is obscure. It has been suggested that it may 
be due to the rubbing of the shirt collar. 

Diagnosis.— If the characteristics of the disease are 
remembered, there should be no difficulty in diagnosis. 
In sycosis we have no hard tumors, and the large hairs 
are surrounded by pustules. Warts are not so hard, do 
not tend to increase in size, and do not become keloidal. 

Treatment. — It has been recommended to use sul- 
phur preparations in the early stages, and in the latter 
stages to apply a mercurial plaster for one or two weeks, 
alternating it with a 10 to 20 per cent, resorcin or chrys- 
arobin plaster. These means usually are useless. When 
the keloidal masses have formed they are as rebellious 
to treatment as keloid usually is. Destruction by elec- 
trolysis, and cauterization by the high-frequency current, 
or x-ray offer the best prospects of success. The latter 
must be pushed to the production of an erythema, and 
repeated when that subsides. Curettage and multiple 
scarifications may help. 

Prognosis. — So far as reported, the growths are benign 
and have no effect upon the health of the patient. They 
are progressive and show no tendency to spontaneous 
recovery. They are obstinate to treatment and prone 
to relapse. 

Dermatitis Psoriasiformis Nodularis. — See Parakeratosis 
variegata. 

Dermatitis Repens. — Crocker first described this dis- 
ease as a spreading dermatitis, usually following injuries, 
and probably neuritic in character, commencing almost 



DERMATITIS FROM X-RAYS 199 

exclusively on the upper extremities. It begins about 
some slight injury, as of the finger-nails, as vesicles 
or a bulla which, on breaking, leave a raw and oozing 
surface. The border of this area is raised up by a clear 
or turbid exudation, and the disease spreads over the 
affected part with a well-defined undermined advancing 
edge; or extension may take place by the appearance 
of new vesicles or bulla just beyond the border. Occasion- 
ally the disease spreads without exudation. The character 
of the eruption suggests a parasitic complication, if 
not cause. The eruption resembles eczema rubrum by 
its raw, oozing, reddish surface, but its sharply defined, 
undermined, spreading edge distinguishes it. In some 
cases it is papular and in others bullous in character. 
It runs a chronic course, sometimes leaves a superficial 
atrophy on healing, and is obstinate to treatment. After 
removing any loose old skin the disease yields best to 
antiseptics, such as lactate of lead, hyposulphite of 
sodium, permanganate of potassium, 10 per cent., sali- 
cylic acid, boric acid, and white precipitate ointment. 
In very obstinate cases ,T-rays might be used. 

Dermatitis from Rontgen or X-Rays. — The dermatitis 
may not appear until some days or weeks after the 
exposure. The patient first notices an erythematous 
patch corresponding to the point of impact of the rays, 
attended by swelling of the skin. This is the mildest 
form and may soon disappear. In most cases the part 
is painful and the redness increases in area and assumes 
a purple hue. The pain when present is deep-seated 
and aching. Pigmentation of the skin may either precede 
or follow this form of dermatitis. Vesicles and sometimes 
bullae form, and later the central part of the patch becomes 
raw, moist, and tends to remain for months without 
healing. Or a dry slough may form which, after a time, 
separates and leaves an ulcer, which may not heal for 
years. A keratosis may develop upon the backs of the 
hands of those constantly using the .T-rays, and these 



200 DISEASES OF THE SKIN 

warty growths are liable to become epitheliomatous. A 
sclerodermatous condition of the hands is also met with. 
The hairs and nails may be shed, but they are not per- 
manently lost, as a rule. It is not determined what the 
cause of the dermatitis is. There is a certain amount of 
idiosyncrasy shown in some cases. The placing of lead- 
foil over the sound skin, about the part to be operated 
on, will prevent burning. As the cases arise on account 
of too long exposure with a tube placed too near the 
subject, or too frequent exposures, short sittings not too 
near each other, filtration of the rays and the greatest 
possible working distance would seem to be the most 
rational prophylaxis. 

Treatment. — In the more superficial burns boric acid 
dressings do well. The deeper burns are very intractable. 
They seem to do best under wet dressings of normal salt 
solution, or diachylon ointment. Pusey commends the 
latter for the keratotic changes on the backs of the hands. 
In some cases the patch has been excised in the hope of 
obtaining a healthy surface. 

Dermatitis Seborrheica, or Eczema Seborrhoicum. — Symp- 
toms. — The starting-point of almost all cases of sebor- 
rheal dermatitis is the scalp; more rarely the margin 
of the eyelids, the axilla, bend of the elbows, or cruro- 
scrotal fold. Upon the scalp the disease begins as small 
papules, either singly or in groups. These grow per- 
ipherally and coalesce to form large polycyclic or ser- 
piginous patches, which are covered partially or com- 
pletely by rather coarse, loosely adherent, yellow, and 
distinctly greasy scales or crusts. These tend to adhere 
to the hairs and may mat them together. The hair 
is usually oily but may be abnormally dry. A pro- 
gressive alopecia pityroides may show itself, the scali- 
ness decreasing with the loss of the hair to make way 
for a hyperidrosis oleosa. A seborrhea may complicate 
matters. Under the crusts or scales the scalp may 
be pale or slightly reddened. In the majority of 
cases the disease is confined to the scalp. The scaling 



DERMATITIS SEBORRHOICA 201 

and crusting may increase, a corona seborrhoica may 
form along the hair line, and the affection may extend 
upon the temples, over the ears to the neck, or on the 
nose and cheeks. Or the catarrhal symptoms may be 
pronounced, and a moist eczema affect the scalp and 
ears, and, in children, the cheeks and forehead. There is 
usually pruritus. It will be readily recognized that the 
slightest form is the pityriasis of the older authorities, 
the more pronounced form their seborrhea sicca, and the 
most pronounced form their seborrhea with dermatitis. 

From the scalp the disease may spread to other parts of 
the body, sometimes proceeding gradually from above 
downward; sometimes appearing in places far removed 
from the scalp, the intervening regions being free. Next 
to the head, the sternum is a favorite site for the erup- 
tion, where it most commonly assumes the crusted form, 
and most rarely the moist form. The sternum is affected 
secondarily to the scalp. The crusted form is in round or 
oval patches the size of the finger nail; these group and 
partly coalesce, forming patches the size of a silver half- 
dollar, having a scalloped border. The color is yellow, 
with a delicate red border. These may clear up some- 
what in the centre and form circles, enclosing a yellowish 
centre; or break and form bow-shaped figures with the 
convexity outward. The lesions of this form are usually 
covered with a greasy crust. The back especially between 
the scapula is similarly affected. (This is Duhring's 
seborrhea corporis.) 

In the axilla we meet most commonly with the moist 
form, and here it shows a tendency to spread with rapidity 
upon the thorax. From the shoulders it spreads down 
upon the arms almost always in the form of yellowish-red 
crusted papules, which tend to unite in patches, and also 
to form rings. At times it may look very much like 
psoriasis. It has usually a well-marked border. It 
shows a predilection for the flexor surfaces. The backs 
of the hands and fingers are often affected with a moist 
eczema, the trunk and arms escaping. 



202 DISEASES OF THE SKIN 

Upon the palms and soles we find little heaped-up 
masses of scales corresponding to individual coil glands 
and resembling psoriasis guttata. Later the epidermis 
peels off, but there is never any moisture. 

The crusted form generally appears in ring or serpigi- 
nous patches on the trunk, buttocks, and hips. The 
cruroscrotal fold and the approximating surfaces of the 
thigh and scrotum are favorite locations for the disease, 
probably forming here many of the so-called cases of 
eczema marginatum in its dry form with festooned margins 
to the patches, or as an intertrigo when it is more moist. 
The thigh and extensor surface of the knee are but little 
affected, while the popliteal space and the leg often are, 
either in the large papular or the thick-crusted form. 

Upon the bearded portion of the face, when the beard 
is worn, we find a diffused pityriasis, or circumscribed, 
reddened, itchy patches. Upon the face of women and 
the unbearded portions of the face in men we have 
circumscribed, scaly, yellowish, or yellowish-gray, slightly 
elevated patches, mostly on the forehead, cheeks, and 
nasolabial fold. There may also be red papules, free 
from scales or with fine yellow ones, with redness of the 
skin between the papules. The face is the favorite 
location for a moist seborrheal dermatitis in children 
especially. The eyebrows are often involved as well as 
the eyelids. The latter are often swollen, and red and 
scaly. The vermilion borders of the lips may be affected, 
and the lips swell, scale, crust, and perhaps crack. The 
disease may attack both the outer parts of the ear 
and the external auditory canal. Scaliness, itching, and 
great increase of cerumen mark the process in the latter 
situation. 

Etiology. — Seborrheal dermatitis occurs at all ages 
and in both sexes, but it is especially prevalent between 
puberty and thirty years of age. It is more frequent in 
men. Though most of the patients with it seem to be 
in good health, careful inquiry will bring out the fact 
that they either are not in perfect condition or they are 



DERMATITIS SEBORRHOICA 203 

living unhygienic lives. Elliot thinks that an in-door 
life favors the disease. It is in all probability a parasitic 
and contagious disease. The bottle bacilli of Unna 
and the polymorphous cocci with gray colonies of Sa- 
bouraud are constantly present on the scalp, and the 
latter's microbacilli of seborrhea is found in the mouths 
of the hair follicles. Its spread is favored by neglect 
of the hygiene of the scalp. Barber shops doubtless 
are distributing centres of the malady. It is quite im- 
possible to estimate the prevalence of the disease, as 
only the more pronounced cases are seen by the physician. 

Pathology.— According to Darier 1 the disease re- 
sembles psoriasis histologically. On the surface of the 
skin is a thick scale composed of nucleated, cornified 
cells, between the layers of which are masses of dried 
serum and leukocytes. Parakeratosis may be continuous 
throughout the lesion or only in places. There is acan- 
thosis and lengthening of the papillse. In the latter 
are small areas of spongiosis and abundant cellular 
infiltration. When these areas of spongiosis reach the 
horny layer, they become dry, and enter into the crust 
formation. There is papillary oedema and cellular infil- 
tration about the bloodvessels. The sebaceous glands are 
normal. 

Diagnosis. — Many cases formerly regarded as eczema 
are now included in seborrheal dermatitis. In diagnosis 
stress is laid upon the fact that the disease begins upon 
the scalp and spreads from there downward in a more or 
less capricious manner; upon the more or less absence of 
itching; upon the superficial character of the lesions, 
their tendency to take on definite forms, their yellowish 
color, and the greasy feeling of the crusts. In all these 
things the disease differs from an eczema. At times 
seborrheal dermatitis of the body bears so striking a 
likeness to pityriasis rosea that it is hard to differentiate 
the two. Pityriasis rosea does not occur on the scalp; 

1 Precis de derm., p. 78. 



204 DISEASES OF THE SKIN 

but as seborrheal dermatitis is of very common occur- 
rence on the scalp, and may be found in conjunction 
with pityriasis rosea; this is not of much aid in diagnosis. 
The rings of pityriasis rosea are not so greasy and yellow, 
have fawn-colored, dry centres, and lack the punctate 
border so often seen in seborrheal dermatitis. The 
papular lesions of pityriasis rosea are not so much raised 
as are those of seborrheal dermatitis and not so evidently 
related to the follicles of the skin. Pityriasis rosea 
commonly runs a rapid and self-limited course, whereas 
seborrheal dermatitis is chronic. If pityriasis rosea 
occurs typically upon the trunk, there is no difficulty; 
but when scaly ring-shaped patches occur on the limbs 
alone a positive diagnosis cannot be made without a 
good deal of study. 

The psoriasiform seborrheal dermatitis differs from 
psoriasis in occurring in locations not typical of psoriasis, 
and in having a more yellowish cast of color, and more 
greasy, yellowish scales. Many cases can be diagnosti- 
cated only by taking into consideration the probabilities 
for and against psoriasis. 

Seborrhea and both forms of pityriasis of the scalp 
are non-inflammatory. Lupus erythematosus of the scalp 
is an atrophic disease, while seborrheal dermatitis does 
not destroy the scalp. 

Treatment. — It is necessary to pay special attention 
to the scalp in every case, as that is the place of de- 
parture in almost all cases. In the treatment of the 
disease we have three useful drugs: sulphur, resorcin, 
and mercury. If a patient comes with the dry and scaly 
form of the disease, no matter whether there is or is not 
apparent inflammation, the best thing to prescribe is 
sulphur, and the most elegant prescription is: 



— Sulphur, prsecip., 


3 iiiss 


14 


Cerse albse, 


5iiiss 


14 


01. petrolati, 


Biiss 


78 


Aquae rosae, 


giss 


46 


Sodse biborat., 


gr. xviij 


1 



-Hydrarg. bichlorid., 


gr. j 


Resorcinol seu Euresol, 


3j 


01. ricini, 


3ss 


Alcohol, 


ad §iv 



DERMATITIS SEBORRHOICA 205 

This is known as Sulphur Cream. It is to be applied 
once a day for two or three days. Then the scalp is to 
be washed. After drying, the ointment is to be applied 
and repeated every other day for ten days. After wash- 
ing and drying, the ointment is to be applied three times 
a week, and so the number of applications are to be 
reduced until the ointment is used once or twice a week, 
and the head washed every two or three weeks. The 
efficacy of the ointment is sometimes increased by the 
addition to it of 2 or 3 per cent, of salicylic acid. 

Where there is a good deal of oiliness of the scalp, 
and where the use of an ointment is objected to, this 
prescription may be given: 

1$ — Hydrarg. bichlorid., gr. j 06 

4 I 

2 

120 j 

This is to be applied morning and night by means of a 
perforated cork, if for a man; or a medicine dropper, 
or tooth-brush, if for a woman. Once every few days, 
if the scalp becomes dry, it is well to rub in a little sweet 
almond oil, or an ointment containing 2 or 3 per cent, 
of resorcin. The strength of the resorcin in the pre- 
scription must be increased from time to time up to, 
perhaps, 10 per cent. Care must be taken not to use 
resorcin on blond or gray hair, as it stains the hair a 
green color. The lotion may cause an exfoliation of the 
scalp, which does no harm, and usually does not recur. 

As a substitute for the sulphur ointment, and in those 
who cannot use sulphur, this prescription will be found 
excellent : 

1$ — Hydrarg. amnion., gr. xx-xl 1.33-2.66 

Hydrarg. chlor. mitis, gr. xl-lxxx 2.66-5.33 

Vaselin, ad §j ad 32 

This is known as Bronson's Ointment. It is to be used 
in the same w T ay as the sulphur cream. 

Salicylic acid, 3 to 5 per cent., in the form of a lotion 



20(5 DISEASES OF THE SKIN 

for the scalp, and of an ointment for the body; and the 
ammoniate of mercury ointment in full strength or 
diluted, are both excellent. Hodara 1 recommends in 
the dry forms of the disease an ointment composed of 

R— Chrysarobin, gr. i ad If 1.02— .1 

Ichthyol, gr. § ad vj .04-. 1 

Vaselin, ad giij ad 100 | M. 

which is to be applied at night and removed with cold 
cream in the morning. If reaction occurs, the ointment 
should not be used until it subsides. On the scalp the 
chrysarobin may be used in the same strength in alcohol, 
with the addition of a little castor oil. At times very 
obstinate patches of psoriasiform seborrheal eczema will 
be met with on the scalp, especially at the margin of the 
hair over the forehead. The best application for these is 
a 10 per cent, solution of chrysarobin in a 50 per cent, 
aqueous solution of ichthyol. This was first used by 
Dr. C. T. Dade, of New York. 

The prescriptions given for use on the scalp may be 
used for the disease elsewhere on the body, but these 
ointments are to be preferred to lotions. 

Prognosis. — There is practically no permanent cure 
of the disease, as it affects the scalp, because of the 
multitude of hair follicles that are the hosts of the parasite. 
By constant care of the scalp the disease is readily held 
in check, but when the scalp is neglected, a relapse is 
to be expected. The disease occurring on the body is 
usually easily cured, though relapses are common. 

Dermatitis Traumatica. — This term is used to comprise 
all inflammations of the skin that are due to traumatic 
influences, such as blows, rubbing, and the like. It 
presents the usual signs of inflammation to a greater or 
less extent, even up to gangrene, according to the degree 
of traumatism and the susceptibility of the individual 
skin. The irritation of the skin due to scratching is a 
common instance of this form of dermatitis. Under 

1 Monatshefte f. prakt. Dermat., 1899, xxix, 264. 



DERMATITIS VEGETANS 207 

certain circumstances it easily develops into an eczema. 
The chafing of the skin met with in horseback-riding, 
in those unaccustomed to the exercise, is another common 
instance. 

Treatment. — The treatment of this form of dermatitis 
should be soothing, such as by the free use of dusting 
powders, alkaline lotions, or mild ointments, such as that 
of the oxide of zinc. Unna 1 recommends for the preven- 
tion of the dermatitis due to horseback-riding, that the 
part should be smeared with a weak resorcin or ichthyol 
ointment. 

Dermatitis Vegetans. — Synonym: Pyodermatitis vege- 
tans (Hallopeau). 

This disease is thought by some to be an anomalous 
form of pemphigus vegetans, and by others as belong- 
ing to herpetiform dermatitis. But as it lacks the 
gravity of the former, and yields readily to antiseptic 
cleanliness, and, moreover, as a number of cases begin 
as eczematous lesions, it is, at least, in many cases 
an independent disease. G. W. Wende 2 has reported 
ten cases occurring in infants, six of which developed 
in the course of eczema. They occurred on the face, 
scalp, wrists, arms, and legs. In his cases the disease 
began as papulopustules, which soon dried up or rup- 
tured. On the red base thus formed vegetating masses 
developed. They were from split pea to walnut size 
or larger, and elevated from one-quarter to one inch 
above the level of the skin. They often showed miliary 
pustules, especially at their borders, exuded purulent fluid 
on pressure, and presented a warty appearance when the 
crusts or scales were removed. Microscopic examina- 
tion showed staphylococci. 

Balzer, Gougerot, and Burnier 3 found in a similar 
case the mycoderma pulmoneum. Their case ran a 
slow course with relapses, and in places left cicatrices. 

1 Monatshefte f. prakt. Dermat., 1888, No. 21. 

2 Jour. Cut. Dis., 1911, xxix, 473. 

3 Ann. derm, et syph., 1912, cxi, 461. 



208 DISEASES OF THE SKIN 

It is very probable that this form of dermatitis may 
arise secondarily to several diseases, and is due to some 
hitherto undiscovered cause. 

The treatment is cleanliness by the use of peroxide of 
hydrogen, and the application of ammoniate of mercury, 
or other antiseptic ointment or lotion. 

Dermatitis Venenata. — Redness, swelling, and heat, fol- 
lowed or attended by the formation of a vast number of 
small, closely crowded vesicles that may remain isolated 
or run together and form bullae, are the symptoms that 
constitute this form of dermatitis, the cause of which 
is always some sort of irritant applied to the skin. The 
irritant is usually of a chemical nature, and quite com- 
monly is derived from plants. 

Rhus Poisoning. — The most frequent cause of derma- 
titis venenata is contact of the susceptible skin with the 
leaves of the rhus toxicodendron, the poison ivy, and the 
rhus venenata, the poison sumach, and the rhus diversi- 
loba, the poison oak. The mildest degree of irritation is 
an erythema. Commonly the reaction is more marked. 
The patient first experiences a little burning or itching, 
and attention being drawn to the part, it is found to be 
reddened and swollen. In some cases we may have 
wheals. In a few hours papules, then vesicles will 
form and perhaps bullae . The swelling may be intense, 
so as, on the face, completely to close the eyes, and on the 
scrotum to give the appearance of an immense hydro- 
cele. The vesicles may be present in a countless multi- 
tude. The acute developing symptoms may last several 
days, and then gradually subside. The vesicle contents 
either dry up or discharge upon the skin. The parts 
crust, the swelling and redness slowly disappear, and the 
skin once more becomes normal. The parts most usually 
affected are the hands and face in both sexes, the penis 
in the male and the breast in the female — that is, those 
parts that come in direct contact with the poison, or to 
which it is most liable to be conveyed by the hands. 



DERMA TI TIS V EN EN A TA 



209 



In some rare cases, and in extremely sensitive individuals, 
the whole body may be affected, and there may be grave 
constitutional disturbances. These bad cases are met 
with, for the most part in children whose legs are uncov- 
ered, and whose resistance to the poison is not great. 
Most persons, perhaps, are not susceptible to the poison. 

Fig. 26 




Dermatitis venenata from poison ivy. 1 



Some few are so susceptible that even having the wind 
blow on them from over one of the plants, especially 
on a warm day when the sap is flowing, will cause the 
dermatitis. Negroes are almost immune. 

It is not true that the dermatitis will relapse after an 
interval of time, but it has been observed that an eczema 

1 From a photograph by Dr. H. W. Blanc, of New Orleans. 
14 



210 DISEASES OF THE SKIN 

may follow the dermatitis, and that this may show a 
certain amount of periodicity in its outbreaks. White 
says that while the poison may be most active in the 
flowering season, it is sufficiently active in all seasons, 
and that the poison resides not only in the leaves, but 
also in the wood, bark, and fruit. The disease is not 
contagious after the parts have been well washed. 

Pathology. — The cause of dermatitis venenata when 
due to ivy or dogwood is toxicodendric acid. According 
to S. F. Acree and W. A. Syme, 1 it is a poisonous tar, 
gum, or wax, which is non-volatile and a complex sub- 
stance of a glucoside nature. It is easily oxidized by 
permanganate of potassium; and precipitated into an 
insoluable lead compound by acetate of lead. 

Diagnosis. — The eruption differs from that of eczema 
in seeking the inner sides of the fingers, the hands, face, 
breast, and genitals; in the greater amount of swelling 
that commonly attends it; in the vast number of crowded 
together, " lurid" vesicles; and in the occasional occur- 
rence of the eruption in the early stage in streaks, sugges- 
tive of striking against the plant. A history of having 
been in the country will sometimes be an aid in diagnosis. 

Erysipelas of the face sometimes needs to be differen- 
tiated. If the hands or genitals are affected at the same 
time with the face, that will decide in favor of derma- 
titis venenata. Besides this, erysipelas almost always is 
attended by constitutional disturbances, and it spreads 
with a raised border. 

Treatment. — : A susceptible person should always 
scrub his hands and face with hot soapsuds if he has 
been exposed to poisoning. It is well to do this once 
as soon as redness appears. Morris 2 advises the appli- 
cation of alcohol after the soap. A saturated solution 
of bicarbonate of soda, that can be procured anywhere, 
will afford relief promptly. The parts are to be kept 
constantly covered with lint or absorbent cotton con- 

1 Jour. Biolog. Chem., March, 1907. 

2 Jour. Amer. Med. Assoc, 1911, lvii, 102. 



DERMATITIS VENENATA 211 

tinuously saturated with it, or with lime-water. At 
night we cannot use this if the patient sleeps, as the 
cotton or the lint dries. So it is better at this time to 
use some simple ointment, as cold cream, oxide of zinc, 
or diachylon diluted one-half, the last being the best. 
This treatment commends itself on account of its efficacy, 
cheapness, safety, and accessibility. Ichihyol in aqueous 
solution from 10 to 40 per cent, strength is highly com- 
mended by some. White recommends black wash [calomel, 
3j (4); aq. calcis, Oj (500)], applied for half an hour 
at a time two or three times a day. He cautions against 
the danger of using it in extensive cases. As a substitute 
for it he gives: 



1$ — Zinci oxid., 3iv 16 

Ac. carbol., 5j 4 

Aq. calcis, ad Oj ad 500 



M. 



Sugar of lead in solution is a well-known remedy, and 
is efficacious but dangerous. Morrow 1 recommends: 



1$ — Sodii hyposulphitis, 5j 32 

Glycerini, gss 16 

Aqua?, ad gviij ad 250 



M. 



Acree and Syme recommend a 1 per cent, aqueous 
solution of permanganate of potassium used as hot as 
can be borne for half an hour. They say the staining 
of the skin can be removed by soap and water. They 
caution against the use of alcohol, which tends to spread 
the poison. The following formula may be tried: 



-Zinci oxidi, 




Magnesise carbonat., 


aa 3J 


Aristol, 


5ij 


Aquse rosae, 


ad giv 



120 



M. 



It sometimes aborts the disease when used early. 

After the acute stage has passed the case should be 
treated like an eczema. If the constitutional disturbance 
is marked, the patient should be cared for upon general 
medical principles. 

1 Jour. Cutan. and Ven. Dis., 1886, iv, 180. 



212 DISEASES OF THE SKIN 

While the poison oak, or ivy, causes the symptoms 
most often spoken of as dermatitis venenata, there are a 
number of other plants that will produce like, if not so 
severe, symptoms. Of the commoner ones we find the 
oleander, Jack-in-the-pulpit, skunk cabbage, bitter orange, 
May apple, arnica, burdock, golden rod, and common 
daisy. The Japanese primrose, a favorite house plant, 
poisons many. The irritation is thought to be caused by 
needle-shaped crystals, and large and small thrombic 
prisms in the secretion exuding from and covering the 
glandular hairs of the leaves. 1 But space will not allow 
of a complete list of these. Goa powder and its derivative 
chrysarobin, produce a marked dermatitis in addition to 
the mahogany-staining of the skin. The action of croton 
oil, mustard, stinging nettle, and oil of turpentine is 
well known. Tar may excite a general dermatitis or an 
acne-like inflammation of the follicles called "tar acne," 
the follicles of the skin being stopped up and their mouths 
filled with a plug of black tar. A somewhat similar 
eruption is seen in workers in flax and paraffin. Workers 
in picking and packing peaches may have an eczematous 
dermatitis develop upon the wrists, forearm, neck, and 
upper part of the chest. 

A great number of chemicals produce dermatitis of 
varying degree. Pyrogallic acid produces a burning and 
inflammation, and covers the part with a black coating 
on account of its oxidation. Xot only does it destroy 
diseased tissue, but it may cause also sloughing of the 
sound skin. Chloroform will blister if prevented from 
evaporating. This peculiarity is sometimes employed 
for vesication. The strong acids destroy the skin, as 
also arsenic. Sulphur, iodin, iodoform, creolin, mercurial 
preparations, chloride of zinc, bichromate of potash, and 
caustic potash cause varying degrees of dermatitis. 
Electricity will redden and inflame the skin, and not a 
few cases of dermatitis have resulted from wearing 

1 Foerster: Jour. Amer. Med. Assoc, 1910, lv, 642. 



DERM ATOLY SIS 213 

clothing dyed with anilin dyes. It is said that the 

brown-tail moth coming in contact with the skin will 

cause an eruption like dermatitis venenata. Its hairs 
contain an irritant poison. 

Dermatitis Verrucosa. — Occasionally we see cases marked 
by patches which are circumscribed, raised, with their 
surfaces presenting a markedly uneven, papillomatous 
or warty appearance. There is a narrow zone of redness 
about the patches. A drop or two of serum may ooze 
from them, or thick pus. Pressure upon them will 
usually force out pus. There may be only one patch, or 
several patches. Commonly they will be on the same 
part of the body. The patients are usually in poor 
physical condition. They may be the subjects of other 
skin diseases, such as chronic eczema. They do not 
complain of itching. The disease seems to be due to 
streptococcic or staphylococcic infection, and to yield 
best to snug bandaging with the ammoniate of mercury 
ointment, or salicylic acid ointment; or to wet dressing 
of antiseptic character. At times the disease is very 
intractable. It is probably allied to dermatitis vegetans. 

Dermatolysis. — Synonyms: Chalazodermia; Cutis laxa 
seu pendula; Pachydermatocele, Loose skin. 

This term is applied to two entirely different diseases 
of the skin. In one we have folds of loose, thickened 
skin, and subcutaneous tissue that sometimes form huge 
masses hanging down from the side of the face, trunk, or 
any part of the body. The skin is soft and does not 
appear altered, excepting that it is pigmented to a certain 
extent. This form is really a species of fibroma. True 
dermatolysis is a yet more rare affection, in which, owing 
to some defect in the attachments of the skin, it can be 
pulled away from the body like the skin of a cat. The 
"Elastic-skin Man" is an instance of this. There have 
been several of these freaks. The one mentioned could 
pull the skin from his chest up to his eyes. The condi- 



214 DISEASES OF THE SKIN 

tion is congenital, but can be increased by cultivation. 
There are no other changes in the skin itself. 

Treatment. — The treatment of the first variety is by 
excision before it becomes too large. 

Dermographia. — See Urticaria factitia. 

Dhobie Itch. — According to Stelwagon, in the tropics, 
during the warm weather the fungi of ringworm, chromo- 
phytosis, and erythrasma cause a dermatitis of the axilla, 
crotch, and feet, which is characterized by a more or 
less pronounced festooned border. The patches are very 
pruritic, and when scratched become raw. Boils and 
abscesses, the result of secondary infection, often com- 
plicate matters. With the advent of the cooler weather, 
the disease tends to recovery, and is well in winter time. 

Treatment. — The treatment is cleanliness of the patient 
and the use of antiseptics, such as boric acid, salicylic 
acid, bichloride of mercury, and the like. 

Diabetic Eruptions. — According to Brocq, they may be 
divided into two great classes: (1) Those in direct 
relation to alterations in the general economy, such as 
pruritus, chronic papular urticaria, acne cachecticorum, 
erythema, lichen, eczema, herpes, ecthyma, furuncle, 
carbuncle, xanthelasma, gangrene. (2) Dermatoses due 
directly to the contact of the secretions of the body 
charged with sugar, and more especially eczema of the 
genitals caused by contact with the urine. 

Kaposi 1 has described a bulloserpiginous gangrene 
of diabetics which begins as a disseminated eruption of 
bullae upon the extremities. The bullae dry up in the 
centre into a black crust, while at the periphery there is 
a ring of fluid pushing up the epidermis. When the crust 
is removed, sphacelated skin is exposed, which separates 
and leaves a red, granulating surface. The penis is a 
favorite site for this form of gangrene. It must be 
treated on general surgical principles. 

1 Wien. med. Presse, 1883. 



DISTICHIASIS 215 

Diphtheria of the Skin. — Diphtheria of the skin takes 
the form of ulcers, which at first are small and superficial. 
Later they become confluent, large, of irregular shape, 
with scalloped borders running out into the sound skin. 
Their edges are slightly infiltrated, intensely red, here 
and there undermined, but usually perpendicular. Their 
floor is covered with a grayish-white, adherent diphther- 
itic membrane. They have only a slight odor. When 
cleaned they heal rapidly. There is slight constitutional 
disturbance, with temperature not high. They may 
occur without the presence of diphtheria elsewhere, 
and are most often seen in the crotch where intertrigo 
is present. Diphtheria bacilli are found in the ulcers. 

Sometimes the disease may rapidly spread over large 
surfaces, when the skin becomes bathed with a serous 
discharge, assumes a grayish or blackish tint, and has a 
putrid odor. Pustules and bullse may occur with the 
Loeffler bacilli found in them. 

Diagnosis. — Hospital gangrene differs from diphtheria 
in having ulcers covered with a dirty grayish-green to 
blackish membrane, many millimeters thick, which is 
gelatinous, pasty, and looks like the result of burning 
with an acid. They are surrounded by a bright inflam- 
matory zone, and have a foul odor. High fever and 
severe constitutional disturbance accompany them. There 
are no diphtheria bacilli present. Ecthyma infantile 
always begins as a pustule; the ulcers formed are more 
superficial, oval, and without diphtheritic membrane. 
Ulcus molle is crater-form, with undermined edges. It is 
inflammatory, swollen, and without diphtheritic mem- 
brane. 

Treatment. — The ulcers are to be cleaned with anti- 
septics and antitoxin administered. 

Distichiasis.— This is a congenital or acquired con- 
dition of the cilia, in which they grow in two distinct 
rows, the inner row being directed inward so as to scrape 
the cornea. According to Michel, generally the outer 



216 DISEASES OF THE SKIN 

third of the upper lid is affected alone, the deformity 
is symmetrical and bilateral, and of embryonic origin. 
Electrolysis offers the best method of relief. These cases 
belong to the ophthalmic surgeon. 

Dracontiasis. — See Guinea-worm disease. 
Drug Eruptions. — See Dermatitis medicamentosa. 
Duhring's Disease. — See Dermatitis herpetiformis. 
Dysidrosis. — See Pompholyx and hidrocystoma. 

Ecphyma Globulus is described by H. L. Purdon 1 as 
a contagious disease occurring in Ireland. It begins 
as a tubercle which, after a time, softens and is replaced 
by a raspberry-like tumor. All parts of the body may 
be affected excepting the hands and feet. It is chronic 
in its course, but can be cured by application of the 
nitrate of silver. 

Ecthyma. — Synonyms: Furunculi atonici; Phylzacia 
agria; (Ger.) Eiterpusteln; (Fr.) Furoncles atoniques; 
(Ital.) Rogna grossa. 

A cutaneous eruption of deep-seated pustules, with 
hard, elevated, reddened bases, attended by the forma- 
tion of thick, greenish or dark-colored crusts, and followed 
either by cicatrices or dark pigmented spots. 

Symptoms. — As usually described, the disease consists 
in an outbreak of one or more round, flat pustules, whose 
covers are not fully distended, and which have an 
inflammatory areola. In size they vary from that of a 
split pea to that of a finger nail, or larger. At first they 
are white or yellow. Subsequently they may or may not 
become reddish from the admixture of blood. They may 
dry up, forming a crust which, on falling, leaves a healthy 
surface. Or they may rupture spontaneously or be broken, 
and form a thick greenish or blackish crust, under which 
is a raw or superficially ulcerated surface, which on heal- 

1 Dublin Jour. Med. Sci., 1897, ciii, 486. 



ECTHYMA 217 

ing leaves a pigmented or slightly cicatricial spot. In 
subjects in bad hygienic surroundings quite deep ulcers 
may result. These pustules are usually discrete, but they 
may group. They are both painful and tender. Any 
part of the body may be affected, but they are most often 
seen on the extremities, especially the legs, where the hair 
is coarse, the shoulders, and the back. The course of the 
disease may be acute, each pustule lasting five or ten 
days, and the whole disease lasting about tAvo weeks; but 
generally it is chronic, and kept up by the outbreak of 
fresh crops. There is more or less itching, soreness, and 
pain. It is both contagious and auto-inoculable. Febrile 
symptoms may accompany or precede the outbreak of 
the disease, but, as a rule, they are absent. It is, in all 
probability, only contagious impetigo modified by the 
character of the soil upon which it is planted. 

Etiology. — Dirt, want, bad hygienic surroundings, 
the strumous diathesis, or a broken-down, cachectic 
condition brought on by intemperance or dissipation, 
all predispose to the disease. It is quite often seen in 
the genus " tramp." It follows, not infrequent lv, upon 
scratching on account of pediculi and scabies. It is 
most often seen in adults, and is rare in children. Like 
in all other purulent diseases, pus cocci, both staphylo- 
cocci and streptococci, are found in the pus, and are 
the contagious element in the disease which is carried 
from place to place to produce new foci of infection. 
Sabouraud teaches that it is the streptococcus of Fehl- 
eisen that is the specific causative microorganism, 
staphylococci being also present secondarily. 

Diagnosis. — Ecthyma differs from eczema in having 
much larger and deeper pustules, which are discrete and 
not confluent, in the marked areola about the pustules, 
and in the absence of all other signs of eczema. It differs 
from impetigo contagiosa in its pustules being deeper; in 
their location upon the extremities rather than upon the 
face and hands; in not having that flabby, bullous look 
of a burn of the second degree, so common to impetigo; 



218 DISEASES OF THE SKIN 

in having thick greenish or blackish crusts, and no 
straw-colored stuck-on crusts; occurring in more or less 
debilitated adults and not in otherwise healthy children. 
But all these alleged differences can be readily explained 
away by the difference in the character of the soil on 
which the contagious principle is implanted. Ecthyma- 
tous pustules are often seen in connection with impetigo 
contagiosa. From impetigo it differs principally in its 
being a deeper and more inflammatory process, and in 
occurring in debilitated subjects. It resembles the large, 
flat, pustular syphiloderm; but its crusts are not heaped 
up into oyster-shell-like masses, as in syphilis, and when 
they are removed they leave a more superficial, and not 
so punched-out an ulcer. There are more signs of inflam- 
mation than in syphilis, also pain and sometimes itching, 
and an entire absence of other symptoms or history of 
syphilis. It differs from furuncle in having no central 
core, and in not being so deep a lesion nor so painful. 

Treatment. — The first thing to be done in these 
cases is to obtain cleanliness, proper hygienic surroundings, 
and complete abstinence from alcoholics. If there is a 
general debility, tonics must be given, and the dietary 
improved. Locally, all crusts must be removed with 
soap and water, the lesions dressed with an ointment 
containing some antiseptic such as: 

1$ — Hydrag. ammon., gr. xx 1 [32 

Ungt. zinci oxidi, Sj 32 1 M. 

and the parts enveloped in a bandage, where such can be 
applied. An ointment or oil containing 10 (0.64) or 15 
(1) grains of salicylic acid to the ounce (32) will also 
answer well. If ulcerations have formed, they should 
be treated as will be indicated under Ulcers. 

Eczema. — Synonyms: (Ft.) Dartre vive, ou humide, 
eczema; (Ger.) Ekzem, Hitzblatterchen, Flechte, nas- 
sende Flechte, Salzfluss; Salt rheum, Tetter, Humid 
tetter, Scall, Scald, Heat eruption. 



ECZEMA 219 

A non-contagious inflammatory disease of the skin, 
sometimes acute, more often chronic, attended with 
itching, desquamation or loss of the cuticle, and usually 
with the exudation of serous or seropurulent fluid either 
beneath the cuticle or upon the denuded surfaces. It 
may present erythema, papules, vesicles, or pustules, and 
its lesions show a decided disposition to run together 
and form infiltrated patches. 

Symptoms. — This is a most protean disease. There are 
seven prominent symptoms of the disease : 

1. Redness. 

2. Itching. 

3. Infiltration. 

4. Tendency to moisture. 

5. Crusting or scaling. 

6. Cracking of the skin. 

7. Tendency of the lesions to run together and form 
patches. 

In every case there will be four or five of these symp- 
toms present at the same time; or perhaps all of them. 

Eczema begins suddenly, and most often without any 
constitutional disturbance. Should slight fever and 
malaise be present, they are accidental, or an expression 
of that condition of the system that predisposes to the 
disease, and not part of the disease itself. Very often the 
first thing that attracts the patient's attention is itching; 
and when he examines the skin he finds it reddened, and 
either scaly, or covered with papules, vesicles, or pustules; 
or moist. 

The tendency of eczema in all forms is to form patches, 
which are infiltrated to a greater or lesser extent; ill 
defined; shade off imperceptibly into the surrounding skin, 
so that it is hard to say where they end, with outlying 
lesions about them; irregular in shape; of all sizes, some- 
times involving nearly the whole cutaneous surface; 
sometimes swollen, and of dark-red color; sometimes 
with a shade of yellow. Beginning by a few lesions, the 
disease increases more or less rapidly in extent, and it is 



220 DISEASES OF THE SKIN 

by the running together of the individual lesions that 
the patches are formed. It may clear away after a short 
time, or it may last weeks or months, or become chronic, 
showing little tendency to recovery. There is no con- 
stant rule as to the course of the disease, though many 
cases occur and recur at certain seasons of the year; it 
may be in the summer, spring, autumn, or winter. Any 
or all parts of the skin may be affected, but it has a 
predilection for the flexures of the joints, the face, the 
scalp, and the sulcus behind the ear. There may be 
but a single patch or many patches. It commonly affects 
both sides of the body, but with no marked symmetry. 

The subjective symptoms are itching, burning, and a 
feeling of heat and tension. Of these, the most constant 
is itching, which is present in all cases, and is often so 
great as to cause the patient to excoriate the skin by 
scratching. It is subject to exacerbations and remissions. 
The latter may be complete or incomplete. Burning and 
tension are experienced for the most part only at the 
beginning of the attack or during some exacerbation of a 
subacute or chronic case. 

The old definition of the disease was that it is a 
vesicular one. It is well to disabuse the mind of this 
impression at the start, as there is a form of the disease 
that is dry throughout — the erythematous form. Though 
even here the vesicles, though unseen, are present deep in 
the skin. There are five forms of eczema, known as the 
erythematous, papular, vesicular, pustular, and squa- 
mous. Eczema madidans is but a convenient term 
to describe a very moist eczema. Eczema rimosum or 
rhagadiforme is but an eczema in which there is crack- 
ing of the skin, especially about the joints. 

Before discussing each of these forms by itself, it is 
necessary to understand that no one of them, excepting 
perhaps eczema erythematosum, is clear cut and unchang- 
ing. On the contrary, the disease may begin as a papu- 
lar erythema; upon the papules vesicles may form, which 
will run together and soon break down of themselves 



ECZEMA 221 

and form a weeping patch; the subsequent lesions may 
then be pustules, and the final stage through which all 
varieties pass before recovery is the squamous. It is 
common to see several varieties at the same time. 

Eczema erythematosum is most often encountered upon 
the face of an adult, though it may occur elsewhere and 
in children. Beginning as one or more ill-defined red 
patches, it soon forms a continuous patch by the coales- 
cence of the smaller ones. Sometimes the whole face is 
involved, sometimes there are several patches. The 
inflammation at first is often attended by oedema to such 
an extent that the eyes are nearly closed if the disease 
is in their neighborhood. The acuteness of the inflam- 
mation subsides soon. The patient experiences great dis- 
comfort on account of the itching and the burning and 
stiffness of the skin. The skin feels harsh, dry, and 
thickened; it is swollen; its color is bright or dull red; 
there are a slight amount of small adherent scales and 
many small excoriations. If it occurs on contiguous 
folds of the skin, there may be moisture. Upon the face 
vesicles and papules may develop, but they are exceptional. 
After lasting for a time the symptoms may subside and 
recovery take place, the patches fading away altogether 
and not in the centre alone. It may assume a chronic 
form and last for years. It is seen at times upon the 
body in the form of very superficial, pale-red, scaly, 
round, circumscribed patches, and constitutes one form 
of the so-called parasitic eczema. 

Eczema Papillosum. — This is the lichen simplex of the 
old writers. It consists in an eruption of pinpoint to 
pinhead-sized, bright or dull-red, acuminate, discrete, 
grouped, or perhaps confluent papules. They are often 
in relation to the hair follicles. Very frequently the 
papules are capped by vesicles. The papules may remain 
discrete throughout their course, with an occasional small 
confluent patch to betray the nature of the disease, but, 
as a rule, they tend to run together and form patches. 
These patches are frequently no larger than a silver 



222 DISEASES OF THE SKIN 

dollar in size and fairly well denned. This is one of the 
most itchy varieties of this pruritic disease, and the 
scratching consequent upon it produces excoriations, 
and, breaking down the vesicles and papules, gives exit 
to the serum and converts the patch into a moist one. 
This variety is located preferably on the extensor aspects 
of the limbs. The life of the individual papule is com- 
paratively long — days or weeks. It is often obstinate 
to treatment. 

Eczema vesiculosum is the most common and most 
characteristic form, and consists in an eruption of pin- 
point to pinhead-sized, rounded or acuminate vesicles 
that appear upon a reddened surface in immense numbers. 
Prickling and tingling precede the outbreak; intense 
itching and more or less swelling attend it. The vesicles 
group, and perhaps coalesce, and soon rupture of them- 
selves, and discharge a clear, sticky, mucilaginous fluid 
that possesses the quality of stiffening and staining linen, 
and dries into a light-yellow crust. The vesicles rupture 
so early that it is rare for the physician to see a case with 
the vesicles intact. New vesicles form about the patch, 
and break down; the discharge continues from the sites 
of the vesicles, and the crust continuously forms. A 
raw surface is exposed when the crusts are removed. 
Sometimes when the crust is prevented from forming 
on account of friction, there is a weeping surface, which 
has been called eczema madidans or rubrum. Eventually 
the discharge ceases, the hyperemia lessens, scaling takes 
place, and after a time the skin returns to its normal 
condition. This form of eczema seeks the soft parts of 
the skin, the flexures of the joints, the flexor surfaces 
of the limbs, and behind the ears. It may involve the 
whole or nearly the whole cutaneous surface. After it 
has lasted a little while in a part the skin is evidently 
thickened. With it papules and pustules very generally 
are found. 

Eczema Pustulosum. — Like the pustular syphilid, this 
form of eczema occurs in more or less broken-down, 



ECZEMA 223 

cachectic, delicate, or strumous subjects. It is possible 
that there is no pustular form of the disease, what is 
so-called being only a secondary infection with the pus 
organisms. It is the most common form of eczema 
met with in children, and in them occurs by preference 
on the face and head. The eruption consists of small 
pustules that may start as pustules or develop from 
vesicles. They are present in large numbers, and tend 
to break down and form patches covered with greenish 
crusts. If blood is drawn by scratching, the crust will 
be blackish. They are somewhat larger than the char- 
acteristic vesicles, and have a fondness for hairy parts, 
though any part of the body may be affected. This 
and the previous form often merge into each other. It 
may develop from any of the other forms of the disease 
on account of infection by pus cocci. It is not so itchy 
as the other forms. It may change into an eczema 
madidans, and it passes through the squamous stage on 
the way to recovery. 

While the above described forms of eczema are in 
some cases fairly well marked, in very many cases several 
forms will be present at the same time. Thus we may 
see erythematous patches here, while there vesicles may 
form which change into pustules, while scattered about 
are numerous papules. 

Eczema squamosum is the final stage through which all 
forms of eczema pass on their way to recovery. In it 
the skin is dry, red, and covered with thin, papery, flat, 
large or small scales. Itching is pronounced. It is a con- 
dition of the skin in which the formation of its corneous 
layer falls short of perfection. The disease may continue 
in this stage for an indefinite time, a chronic eczema 
with occasional exacerbations. Then it may pass away 
entirely and the skin become quite well; or some local 
injury may cause an acute outbreak of eczema. The skin 
in this form is more or less thickened, and deep cracks 
are liable to form about the joints, because the infiltra- 
tion of the skin interferes with its elasticity, and it breaks 



224 DISEASES OF THE SKIN 

instead of stretching when the joint is extended. While 
the patches are usually ill defined, in some cases they 
will be round, and with well-marked borders. This form 
is spoken of as orbicular eczema. 

Eczema may be acute, subacute, or chronic — terms that 
apply not to the length of time that the disease has lasted, 
but to the symptoms it presents. In acute eczema there 
are the usual signs of inflammation — heat, redness, and 
swelling. There may be constitutional symptoms of 
fever, chills, prostration, and the like. This stage is 
usually of short duration, and passes over into the sub- 
acute stage. Now the swelling lessens or disappears, but 
there is an active evolution of lesions, papules, veiscles, 
or pustules, as the case may be. After a time the chronic 
stage is reached, when the disease takes the form of red- 
dened, infiltrated, scaly patches. It is prone to take on 
acute symptoms under slight irritations. In severe 
attacks of eczema the patient may be confined to bed 
and greatly prostrated. In the great majority of cases 
while the patient suffers much discomfort, he does not 
feel ill. It predisposes to ulceration upon the legs when 
combined with varicose veins, and then is named eczema 
mricosum. This must not be confounded with a some- 
what similarly sounding name, eczema wrrucosum, which 
is a rare form, in which the skin takes on a warty appear- 
ance on account of a hypertrophy of the papillae. 

Etiology. — Like its symptoms, its causes are numer- 
ous. It may arise from purely local causes, but even then 
it is probable that we should assume in most cases a pre- 
disposition on the part of the skin. Thus we have eczema 
of the hands in washerwomen. Perhaps for a score of 
years they had washed in water from the same source 
and with the same kind of soap without eczema. Then 
under the same local conditions, but with some unknown 
internal constitutional state, an eczema breaks out. 
Of external irritants, we have the sun, water, intense 
artificial heat, acids, alkalies, traumatism, rubbing of 
apposed surfaces or chafing by the clothing, parasites — 



ECZEMA 225 

in fact, just the same things as will cause a dermatitis, 
only now the action goes further, and a catarrhal con- 
dition of the skin results. Cold has an undoubted in- 
fluence on the skin, and eczema is more common in 
winter than in summer, and is generally aggravated by 
extremely low temperature, even when the patient keeps 
in the house. It has been observed that children with 
eczema grow worse when it is cold and a high wind is 
blowing, even though they are not exposed directly 
to these conditions. Vaccination may act as a local 
cause. 

Of the internal or predisposing causes, perhaps the 
most common and active is some digestive or intestinal 
disturbance — it may be dyspepsia or malassimilation, or 
derangement of the liver, or constipation. At other 
times the kidneys are at fault. Diabetes and B right's 
disease both predispose to eczema. Chlorosis and anemia, 
uterine disorders and the menopause, and the strumous 
diathesis are at times active factors. Derangements of 
the nervous system are exciting causes; now and again 
we meet with cases which appear suddenly after some 
nervous shock. Rheumatism and gout and varicose veins 
are other predisposing causes. To most of these internal 
causes some external irritation must be added before the 
eczema appears. 

The French school of dermatology has long held to 
its theory of diathesis, and has taught that the dartrous 
diathesis is the cause of eczema. A vulnerability of the 
skin is necessary for the production of an eczema, and 
many patients may fairly be regarded as eczematous, 
just as others may be spoken of as gouty, or rheumatic, 
or psoriatic. This peculiarity or tendency of the skin 
may be inherited, and insofar eczema may be regarded 
as hereditary. 

The disease occurs in all ages, conditions, races, and 

both sexes, and is the dermatosis we are most often called 

upon to treat. It is especially common in children. In 

Bulkley's tables, out of 3000 cases, 676 occurred under 

15 



226 DISEASES OF THE SKIN 

five years of age; and of these, 520 were in children 
under three years. Of the remaining cases, 1234 were 
between the ages of twenty and fifty, and were divided 
about equally in each decade. About one-third of all 
skin diseases are eczema. 

These many etiological factors indicate that it is 
probable that our present eczema is a too composite 
disease, and it is for this reason that attempts are con- 
stantly made to take away certain members of the family 
and form them into separate diseases. Thus far no 
microorganism has been demonstrated as the cause of 
the disease, though the pus cocci are found in the pustular 
form. The vesicles of eczema are sterile, which is evidence 
against the disease being parasitic. Staphylococci are 
doubtless the cause of pustulation, which may be a 
matter of secondary infection. Unna teaches that there 
are two other varieties of the disease: one due to reflex 
nervous irritation, such as is seen during dentition of 
infants, and one dependent upon the tubercular diathesis. 

Pathology. — Eczema is a catarrhal inflammation of 
the skin, analogous to that of the mucous membrane, 
which has its seat principally in the papillary layer of 
the skin and in the rete. This superficial location of the 
disease is the reason why the skin is left unmarked after 
the disease has been recovered from. In chronic eczema 
there is marked cell infiltration of the corium, producing 
the characteristic thickening of the skin. The subcuta- 
neous tissues may be affected by this infiltration. The 
papillae, bloodvessels, and lymphatics are considerably 
enlarged. In advanced cases the skin appendages may 
suffer obliteration. The sticky yellow exudate of eczema 
is made up of serum containing in solution or suspension 
the detritus of degenerated rete cells. This secretion 
when dry forms the peculiar gummy yellow glaze or 
crusts. A trophoneurosis is supposed by many to be 
the cause of the disease when not due to local irritants, 
and Crocker quotes Marcacci as having found changes 
in the sympathetic in a fatal case of universal eczema. 



ECZEMA 227 

Diagnosis. — If the six prominent symptoms of eczema 
are remembered, namely, redness, itching, infiltration or 
thickening, exudation or tendency to moisture, crusting or 
scaling, and cracking, it will be a great aid in diagnosis. 
To them should be added the tendency the disease 
evinces to locate in the folds of the joints, between 
apposed surfaces of skin and behind the ears, and the 
peculiar, mucilaginous quality of the exudate, which 
stiffens and stains linen and glues the hair together. 
Fortunately, a diagnosis of eczema will fit one out of 
every three cases. Here will be given the general diag- 
nosis, reserving for the sections on regional eczema the 
diagnosis of special forms when necessary. 

Dermatitis is often distinguished with difficulty from 
eczema, and frequently passes over into it. As a rule, 
it runs a more rapid course, its vesicles are longer pre- 
served, bullae are apt to form, there is burning rather 
than itching, and it heals readily on removal of the 
cause, which usually is evident. 

Dermatitis exfoliativa is, when fully developed, a uni- 
versal eruption, while eczema is very rarely so. It is 
also dry; and has abundant large scales; while eczema 
will exhibit moisture somewhere, and does not scale so 
abundantly. For further points in diagnosis, see under 
dermatitis exfoliativa. 

Erysipelas is attended by fever and marked constitu- 
tional disturbances, has a sharply defined border, ad- 
vances steadily at its margin, and forms a swollen, deep- 
red patch upon which large vesicles and bullae form. 
The margin of eczema is ill defined, fading off into the 
surrounding skin; its vesicles are pinpoint- to pinhead- 
sized; itching is always present; and there is little or 
no constitutional disturbance. Eczema has a dry, rough 
surface in the erythematous form, while erysipelas has at 
first a smooth and shining one. 

Erythema burns rather than itches; its redness can be 
entirely squeezed out by pressure, leaving a whitish spot, 
and returns promptly when the pressure is removed. 



228 DISEASES OF THE SKIN 

In eczema pressure will cause the redness to disappear, 
but it will leave a yellow stain in its place. Erythema 
lacks the itching, exudation, scaling or crusting, and 
cracking of eczema, is prone to appear upon the back 
of the hands and wrists, and is symmetrical. 

Herpes febrilis resembles eczema only in having vesi- 
cles upon a red surface. It occurs usually in a single 
patch upon the face; its vesicles are discrete, and show 
little tendency to run together; its course is short, and 
it pains or burns, but does not itch. 

Zoster occurs in the form of a number of herpetic 
patches following the course of a nerve, and occupying 
only one side of the body — symptoms that are entirely 
foreign to eczema. 

Impetigo contagiosa occurs for the most part upon the 
face, hands, and exposed parts. Its pustules are large, 
flat, and discrete, not small and acuminate. Its crusts 
are thin and stuck on; not greenish and thick, as in 
eczema. It is a vesicopustular disease, and often pre- 
sents large vesicles or bullae that look like burns of the 
second degree. 

Lichen planus presents papules that are flat, smooth, 
umbilicated, and angular, and has a peculiar violaceous 
hue when its lesions are sufficiently numerous to simulate 
eczema. Eczematous papules are round and acuminate 
and bright red. They are constantly coming and going, 
while those of lichen planus are constant and last for 
a considerable time. 

Lupus erythematosus occurs in sharply defined patches 
which are exceedingly chronic; its scales are adherent; 
its color is peculiar to it; and it produces atrophy of the 
skin. Eczema presents none of these symptoms. 

Mycosis fungoides in its early stage is often indistin- 
guishable from eczema. Usually its patches assume a 
half-moon, horseshoe, or kidney shape. A circular patch 
with a small round patch, bull's eye, in the centre is 
characteristic. These may disappear, to reappear in the 
same or other locality. They also fail to respond to 



ECZEMA 229 

treatment. The diagnosis is at times difficult until the 
characteristic elevated patches appear. 

Pemphigus foliaceus presents raw surfaces that bear 
some resemblance to eczema rubrum; but its large bullae 
and pastry-like crusts, coupled with the generally bad 
condition of the patient, sharply differentiate it. 

Phthiriasis, or pediculosis, shows parallel scratch marks 
over the shoulders, and excoriations about the waist and 
on the limbs where the seams of the clothing come. If 
on the head, the lesions will be on the occiput, and nits 
will be found on the hair of that region or of the temples. 
The eruption to which they give rise is an eczema, but 
the cause of it is evident. 

Pityriasis rubra pilaris has elevated papules about the 
hair follicles of the back of the fingers, and is not particu- 
larly pruritic. It forms well-defined patches that feel 
like nutmeg graters and present no secondary changes. 

Pruritus cutaneous has no lesions, properly speaking, 
and the excoriations met wfth are not in patches, but 
scattered all over the body at intervals and irregularly. 
The itching is more paroxysmal than it is in eczema, 
and is the only symptom that it has in common with 
eczema. 

Psoriasis, when occurring in typical round or oval, 
sharply defined patchs, with silvery scales, offers no 
difficulty in diagnosis from a typical eczema. From 
circumscribed eczema, that occurs occasionally, it may 
be diagnosed by the color — of a brighter red; by the 
scaling, that is whiter, thicker, and more laminated; and 
by finding characteristic patches either of the one or the 
other disease elsewhere on the body. When psoriasis 
occurs in large areas it is diagnosed from squamous 
eczema by its sharply defined border; its marginate form; 
its brighter red; its more abundant, thicker, and whiter 
scales; its fondness for the extensor surfaces of the limbs, 
while eczema seeks the flexor aspects and the flexures 
of the joints; its uniform character and constant dryness, 
against the polymorphous character of eczema and its 



230 DISEASES OF THE SKIN 

moisture; and its history of frequent relapses, always of 
the same sort and always on the elbows and knees. 

Rosacea occupies the middle third of the face from 
above downward, attacking the forehead, nose, and chin; 
while eczema affects the whole or part of the face, but 
never occurs on these limited regions alone; it burns 
rather than itches; it shows telangiectases, and its red- 
ness and occasional discrete, sluggish, superficial pustules 
are very different from either the dry, harsh, scaly, red- 
ness of an erythematous eczema, or the crusted surface 
of a pustular eczema. 

Scabies may be diagnosed from eczema, by its loca- 
tion upon the anterior surface of the wrists, between the 
fingers, and upon the abdomen and buttocks, of both sexes, 
and upon the nipples and breasts of women and the penis 
of males. In children the feet are often affected. The 
presence of cuniculi is diagnostic, but they are hard to 
find in some cases. The eruption in scabies is at times 
an eczema; but it is important to recognize, where pos- 
sible, the cause of an eczema in order to cure it. 

Syphilis like eczema is a protean disease; but it does 
not itch, and that is an important point in differential 
diagnosis. It is true that occasionally a papular or crusted 
pustular syphilid does itch, but the occurrence is so rare 
that it need not here be taken into account. The early 
syphilids are general eruptions, whether macular, papu- 
lar, or pustular, and the efflorescences never run together to 
form patches, though they may show more or less grouping. 
When the other symptoms of syphilis are present, such 
as the initial lesion, mucous patches, and alopecia, there 
can be no difficulty. It is the later manifestations of the 
disease that offer difficulties in diagnosis, and especially 
the grouped papular lesions that occur on the palms in 
the form of scaly patches. In some cases a diagnosis is 
impossible. The most suggestive symptom of syphilis 
is the occurrence of the disease upon the palm of one 
hand alone. The patch will have a wavy outline; will 
be scaly, but not moist or crusted; will often show healthy 



ECZEMA 231 

skin in the middle; and there are apt to be isolated, 
scaly, dark-red papules somewhere in the neighborhood. 
The finding of scars of old lesions, or some other evi- 
dence of syphilis, will aid us. In any doubtful case the 
Wassermann test should be made. 

Trichophytosis corporis when in disk-shaped patches 
that have not formed rings bears at times so close a resem- 
blance to eczema that it is difficult to make a diagnosis at 
once; but in a short time the centre of the disk will clear 
up and the annular ringworm patch will declare itself. 
Eczema does not have annular patches. 

Urticaria, when it has induced itching and has been 
scratched, looks like an eczema. We recognize it by the 
finding of the wheals, or the history of them, and by the 
isolated, scattered distribution of the excoriations and 
papules. Some cases of papular urticaria can only be 
diagnosed after prolonged observation. 

Treatment.— While not a few cases of eczema arise 
from purely local causes, and require only external treat- 
ment, in most cases the patient is not in good condition, 
and he needs treatment quite apart from his skin disease. 
It is well for us to begin the treatment of a case by regard- 
ing it as one of a sick man rather than a sick skin, and 
striving to remedy any disorder of the general health we 
may find. Fresh air, exercise, and attention to diet, here, 
as in general medicine, are" more to be relied on than 
drugs. 

Diet is of special importance. Piffard 1 found that 
56 per cent, of his cases of eczema were carnivorous — 
that is, ate meat three times a day and but little bread 
and vegetables; 40 per cent, omnivorous, and but 4 per 
cent, herbivorous. Many of the patients eat too much 
and exercise too little. Many suffer from distress of 
stomach after eating certain articles. Some eat too 
little, and that of improper sort. The indications for 
treatment are therefore obvious. The greatest difficulty 

1 Materia Medica and Therapeutics of the Skin. Wm. Wood & Co., 
New York, 1881. 



232 DISEASES OF THE SKIN 

we have to contend with is the objection most people 
have to dieting of any sort. 

In an acute eczema of any considerable extent it is 
always best to put the patient on a restricted and simple 
diet, and of these, where milk is well borne, a milk diet 
is the best. Two or more quarts of milk may be taken 
during the day in divided doses, with dry toast or toasted 
crackers and the cereals, excepting oatmeal. A diet of 
rice, plain boiled, and milk answers admirably in some 
cases. After a few days a more liberal diet may be 
allowed, as in subacute and chronic eczema. 

In subacute and chronic eczema meat should be taken 
but once a day, and in the middle of the day when pos- 
sible. Breakfast and supper should be very simple, 
of crackers and milk, bread and milk, or some of the 
grains well cooked and eaten without sugar. There is a 
popular idea that oatmeal is injurious. It is best to 
forbid its use. Fish may be allowed, but not those with 
dark meat or oily. An occasional egg may be eaten in 
the morning, but not every day. No pastry, cake, or 
confectionery should be allowed. Apart from absolute 
simplicity, the patient's taste may be consulted, care 
being taken to avoid anything, that he knows will dis- 
agree with him. It is a good rule to tell the patient that 
he may eat what he likes, in reason, but not of more 
than three dishes at a meal. It is unlikely that he will 
then overeat. Those who eat too little for any reason 
should be directed to take that little more often dur- 
ing the day. Butter may be taken freely. Fried and 
warmed-up meats should be avoided in all cases. Fruits 
fully ripe or stewed can, as a rule, be liberally partaken of. 

All alcoholic drinks must be absolutely forbidden. 
Malt liquors are especially obnoxious to all irritable 
skins. Tea, coffee, and chocolate are best let alone. 
Coffee, one small cup, may be allowed for breakfast; or 
cocoa which is better, if made with a good deal of milk. 
Milk, if it does not constipate, may be allowed, but not 
with the regular meals if the patient is on a usual mixed 



ECZEMA 233 

diet. Water should be drunk regularly, and it is not 
unlikely that much of the benefit derived from visiting 
foreign spas is due to the regular drinking of water. A 
good rule is for the patient to drink a glass of water 
before meals while dressing, a glass of water or other 
fluid at each meal, a glass of water about two hours after 
meals and before going to bed. If preferred, bottled 
table waters may be used. Vichy water may be substi- 
tuted for plain water once or twice a day. Tobacco is 
harmful in some cases. 

In many cases constipation may be the only irregularity 
detected. It is very important to relieve it by diet and 
exercise where possible. If we must needs give medicine, 
the tablet triturates of aloin, belladonna, and nux vomica; 
the pill of iron and aloes; the extract of cascara sagrada, 
with or without nux vomica, which may be administered 
in capsules or as compressed tablets to avoid the disa- 
greeable taste; Startin's mixture: 



M. 



■Magnesii sulphatis, 


5vj-giss 


20-30 


Ferri sulphatis, 


3J 


4 


Ac. sulphur, dil., 


5ij 


8 


Syr. pruni virgin., 


5j 


30 


Aquae, 


ad giv 


ad 120 



Sig. — A teaspoonful through a tube, after meals. 



or any other serviceable remedy may be given. The 
phosphate of sodium is an excellent laxative for children, 
a little of it being put into their milk, to which it gives 
a hardly noticeable taste. 

Exercise in the open air is as necessary for eczematous 
patients as for any other class. It should not be taken 
so as to cause overfatigue. Patients with eczema on 
the face and hands, or with a tendency thereto, should 
always protect the skin by a little powder, calamin lotion, 
or cold cream before going out into the cold, or storm 
of wind or rain. 

Though there is no specific for eczema, there are certain 
drugs that have acted favorably upon the disease in the 
hands of some observers. Arsenic had best be let alone. 
It is only of benefit in chronic scaling cases, and in only 



234 DISEASES OF THE SKIN 

a few of them. The wine of antimony, 5 drops (0.33) three 
times a day, has been found useful. Turpentine, the spirits, 
is recommended by Crocker in obstinate cases. It is given 
in an emulsion with mucilage, three times a day, after 
meals, the dose being 10 minims (0.66) at first, and then 
if tolerated, increased by 5 minim doses up to 20 to 30 
minims (1.33 to 2). While it is being taken not less than a 
quart of barley-water should be drunk, and the last dose 
should be taken not later than six o'clock in the evening. 

In acute eczema, if taken early, sharp catharsis will 
sometimes tend to lessen the severity of the attack by 
reducing the congestion of the skin. In chronic eczema, 
even without evident renal derangement, the acetate 
or citrate of potash in 15 grain (1) doses will prove useful. 
The itching may be so severe in some cases that even our 
local remedies may not allay it, and it may seem necessary 
to give some medicine to procure sleep. Never use 
opium. The bromides, chloral, or phenacetin may be given 
Hyde and Montgomery speak well of calcium chloride 
in full doses. Bulkley recommends tincture of gelsemium, 
of which 10 drops (0.66) are to be given, and repeated and 
increased every half-hour till relief is obtained, or constitu- 
tional symptoms of languor, tranquillity, dizziness, impair- 
ment of vision, and drooping of the lids, are produced. 
Quinin, in \ grain to 15 grain (0.03 to 1) doses, given at 
bedtime, is commended by some for the same purpose. 

Rest in bed is desirable in all severe cases of eczema 
whether they are acute or exacerbations of chronic forms. 

Local Treatment. — In all cases, whether due to 
purely local causes or a combination of these and some 
general cause, local treatment is of the greatest impor- 
tance. The books teem with prescriptions which have 
been found efficacious, and some of them contain so many 
ingredients that it is hard to determine with exactness 
to what the benefit is due. After all, the matter is very 
simple and, if the principles are mastered, little diffi- 
culty will be found in accomplishing the desired end. In 
acute cases, where we have heat and swelling, employ soothing 



ECZEMA 235 

remedies; in subacute cases, where the swelling has subsided 
and where the papulation, vesiculation, pustulaiion, or exu- 
dation are more or less active, use astringent and protective 
remedies; in chronic cases, where we have thickening with 
scaling, stimulate; in all cases protect the shin from external 
irritation. It is better to learn how to use a few remedies 
and to know what to expect from them, than to try 
every new method that appears in the medical press. 

It is a good, broad rule that water should not be used 
on an eczematous skin, as it removes the newly formed 
epidermis and exposes the tender skin to the air. In all 
but chronic cases it should be used sparingly, and only to 
remove dirt, or crusts, or scales, and the skin should be 
at once covered with some protecting powder or ointment. 
If water is used, it should be either rain or boiled water, 
or water with a little soda, one drachm to the basinful, or 
with bran in it. Often it is better to clean the skin with 
an oily lotion or with cold cream than to use water. 

In acute eczema, lime-water, liquor plumbi subacetatis 
dil., lead-and-opium wash, or solutions of borax or 
bicarbonate of soda, 1 or 2 drachms (4 to 8) to the pint 
(500), may be sopped on three or four times a day, 
dusted over with corn-starch, compound stearate of zinc, 
dolomol, bismuth, lycopodium, kaolin, or French chalk, 
and covered with light, old linen or muslin. Veiel 1 recom- 
mends menthol 1 and amyli 99 as a dusting powder. All 
these will allay the itching; but if this is especially 
severe, the following may be used: 

]$ — Camphori, 3ss 2 

Zinci oxidi, 3ij 8 

Amyli, 5iv ad 16 M. 

Startin recommends the following: 

I£ — Zinci oxidi, §ss 16 

Pulv. calaminse praep., gr. xxx 5 

Glycerini, gj 32 

Liq. calcis, 3vij 28 M. 

1 Munch, med. Woch., 1909. 



236 DISEASES OF THE SKIN 

As soon as the early and most acute stage is passed — 
that is, in subacute eczema — a protecting and soothing 
ointment is to be used, and of these no one is safer 
than the standard benzoated oxide of zinc ointment, that 
can be obtained anywhere. If the case be one in 
which there is much discharge, as in pustular, vesicular, 
and weeping eczemas, Lassar's 'paste is better than the 
oxide of zinc ointment, as being a paste it allows the 
discharge to percolate through it. It is made as follows: 



1$ — Zinci oxidi, 

Amyli, aa 5ij aa 8 

Vaselini, gss 16 



M. 



The addition of 10 to 15 grains (0.66 to 1) of salicylic acid 
to the ounce increases its antipruritic quality, but it is 
often too stimulating and must be used with caution. See 
that in it, as in all other ointments, there are no gritty 
particles left. Dreuw 1 advises the addition of 5 to 10 
per cent, of sulphur loti and ichthyol to the ounce (32) 
of Lassar's paste. All ointments must be smooth, or 
they do harm rather than good. In using ointments 
in eczema they should be evenly spread upon cheese-cloth 
folded four times, or upon old washed muslin, in a layer 
as thick as the back of a table-knife blade, applied to the 
affected part and bound down snugly with a bandage. 
They should be changed twice a day, or more often if 
the discharge is profuse. 

Painting a limited moist patch of eczema with a 
solution of nitrate of silver, 3 to 10 grains (0.2 to 0.66) to 
the ounce, is often a most prompt method of curing the 
disease. 

Ointments are objectionable on account of their greasi- 
ness, and where possible it is pleasanter to use lotions. 
Of these, "Calamin Lotion" composed of — 

33 



M. 



-Calamin., 


gr. xx 




1 


Zinci oxid., 


5J 




4 


Glycerin., 


3iv 




16 


Aquae calcis, 


3vj 




24 


Aqua? rosae, 


ad §iv 


ad 


120 



ECZEMA 237 

To this may be added carbolic acid in 1 to 5 per cent, 
strength to relieve the itching. Peroxide of hydrogen 
sopped on exerts a beneficial effect on pustulation. 
In using lotions in cold weather, the patient should be 
advised to warm them to avoid chilling the skin. 

The diachylon ointment of Hebra will often prove 
beneficial, especially after the subsidence of acute symp- 
toms. It is best used diluted with ungt. aquas rosae in 
the proportion of 2 parts to 1. 

Most cases that we are called upon to treat are in or 
near to the subacute stage, as the acute stage soon passes 
off. It is always advisable to begin treatment not too 
boldly. If our protecting and astringent remedies do 
not cure the case after a fair trial, then we should add 
stimulants, and of these one of the most reliable is tar, 
adding it at first in the proportion of about 15 drops (1) 
of the oil of cade to the ounce (32) of ointment-base, 
such as oxide of zinc ointment. Ichthyol, thiol, and 
thigenol may be used in 10 per cent, solution in water 
during this stage. The last is a good antipruritic, and 
they all form protective varnishes on the skin. 

In chronic squamous eczema we need stimulation to 
whip up the circulation, to produce absorption of the 
infiltration of the skin, and to promote a return to health. 
Here tar is one of our most reliable remedies, and it can 
be used in various strengths and ways. We may use 
oil of juniper, oleum cadini, the oil of birch, oleum rusci, 
pix liquida, or coal tar. There is some doubt and diffi- 
culty about obtaining genuine oleum rusci, which is 
largely used by tanners in the preparation of Russia 
leather. The oil of cade is most used. Some prefer 
this ointment: 



\ — 01. cadini, 








Zinci oxidi, 


aa 3 ss-j 


aa 


2-4 


Uguenti. aquse rosae, 


ad gj 


ad 


32 



M. 

Or the cade may be added to the oxide of zinc ointment 
in the proportion of 1 drachm (1) to the ounce (32). Or 



1$ — Picis liquidse, 


5ij 




64 


Potass, causticse, 


Sj 




32 


A quae, 


ad 5v 


ad 


160 



238 DISEASES OF THE SKIN 

pix liquida may be substituted in about double the 
strength. 

Another most excellent way of using tar, and prefer- 
able to the latter, because not so liable to stain the 
clothing, is that proposed by Pick, namely, to make a 
strong tincture of tar, using 40 parts of pix liquida to 
20 parts of alcohol; and to paint the part every night 
with 3 coats of this tincture, letting each coat dry on 
before another is applied. Then cover with oxide of 
zinc ointment, the ointment being changed morning and 
night. 

Bulkley in some cases recommends tar in what he 
names liquor picis alkalinus, which is made as follows: 



M. 



Dissolve the potash in the water and add slowly to the 
tar in a mortar with friction. This is to be used diluted 
twenty or more times with water, and followed by oxide 
of zinc ointment. 

In some very chronic, thickened eczemas the tar may be 
rubbed in pure. If the eczema is very extensive, the tar 
may be used in olive oil or cotton-seed oil and smeared 
over the body. In some cases the tar will give rise to 
systemic poisoning, the urine will become black, and the 
patient will suffer from headache, oppression, nausea, 
vomiting and diarrhea, and the pulse will become fre- 
quent. Of course, under these circumstances the tar 
must be stopped. Veiel 1 recommends in cases in which 
tar is not well borne: 

1$ — Tumenol, gr. xv-xlv 1-3 

Zinci oxidi, 
Talci, m 
Glycerin, 
Aqua? destil., aa p. e. ad S ii j 100 

1 Munch, med. Woch., 1909. 



ECZEMA 239 

Brocq, Jambon, and Dind 1 and Chajes 2 recommend 
coal tar from gas works, both in acute and chronic eczema. 
The affected parts are to be wiped off with moist com- 
presses, and the tar applied with a brush. After allowing 
it to dry for at least twenty minutes, it is to be covered 
over with talcum powder, or a light gauze bandage. 
If there are crusts these should be removed with water, 
the surface painted with a half to 1 per cent, solution of 
nitrate of silver, and the tar used the next day. If it 
causes too much dryness, or the parts are delicate, as 
the scrotum or flexures of joints, the tar should be 
mixed with equal parts of lard. The applications should 
be repeated every two to six days, according to the time 
it takes for the previous application to peel off. 

Sulphur is, next to tar, one of our best stimulating 
remedies in squamous eczema. It is not so reliable, as it 
is more uncertain in its effects. It finds its best use in 
circumscribed patches, and may be used in vaselin or 
simple ointment in the strength of 1 to 2 drachms (4 to 8) 
to the ounce (32). In some skins it produces a good 
deal of dermatitis. 

Green soap is often of the greatest service in chronic 
eczema. It is to be used in the following way: Take 
green soap; warm water; and oxide of zinc ointment 
spread on muslin or linen. Dip a piece of flannel in the 
soap and then in the water, and with it scrub the parts 
vigorously until all the scales are removed and the skin 
looks somewhat raw. Now wash off all the soap with 
plenty of water, dab the part dry with a soft towel, 
immediately cover with the ointment, and apply a 
bandage. The soap is to be used once a day and the 
ointment changed twice a day. 

Caustic potash, 15 grains to 1 drachm (1 to 4) to the 
ounce (32); or salicylic acid, 10 to 20 per cent., in 
other, may be used to reduce very much thickened 

1 Annal. de dermat. et de syph., 1909, x, 1, 22, 170. 

2 Dermat. Zeit., 1909, xvi, 570. 



240 DISEASES OF THE SKIN 

patches. Nitrate of silver, 10 to 15 grains (0.66 to 1) to 
the ounce (32), may also be used; or chrysarobin, 10 
per cent. 

Unguent, hydrarg. ammoniat. is of use in chronic eczema 
of limited area. 

In chronic, thickened eczema a 40 to 50 per cent, 
aqueous solution of ichthyol, well rubbed in once a day 
with a stencil or stiff paint-brush, acts admirably. Both 
thiol and thigenol are artificial ichthyol, possessing its 
good qualities without its odor, and may be used in the 
same way. Resorcin in from 2 to 5 per cent, strength is 
a good stimulating application. Veiel 1 recommends a 5 
per cent, aqueous solution of tannic acid either with or 
without glycerin. 

For the reduction of infiltration and removing the scales 
in a chronic eczema nothing is better for a time than 
sheet rubber applied to the part and bound down with a 
roller bandage. The rubber should be removed once a 
day, sponged off with soda and water, and reapplied. 
The relief to the itching procured by this means is some- 
times surprising. As soon as the infiltration is reduced 
we should resort to our tar remedies for completion of 
the cure. 

Many attempts have been made to find a substitute for 
greasy or oily applications in the treatment of skin dis- 
eases. Thus we have the plaster mulls of Unna, in which 
a plaster mass is incorporated with the mulls. Many 
speak loudly in their praise. Collodion and traumaticin 
have been used, and answer well, the tar, salicylic acid, 
or what not, being dissolved or held in suspension. In 
this way chrysarobin may be used on limited patches 
of chronic eczema. Gelatin preparations are very valu- 
able, and applied either to a subacute or chronic patch, 
especially when there is no moisture, will allay the itch- 
ing and hasten the cure. Unna's gelatin paste sets at 
once. It is composed of: 

1 Archiv. derm. et. syph., 1911, cvi, 277. 



ECZEMA 241 



I*— Zinci oxidi, 30 

Gelatini, 30 

Glycerini, 39 

Aquee, 10 M. 



It forms a hard mass that must be melted before it is 
used. The best way to use it is to put it in a small tin 
saucepan that fits into another pan that holds water, such 
as is used for sterilizing milk or cooking oatmeal gruel. 
This can be heated over a Bunsen burner or spirit lamp. 
When melted and still warm, it is to be painted over the 
part under treatment by means of a wide paint brush. 
Immediately over it is placed a layer of absorbent cotton, 
and over all a roller bandage. This dressing may be left 
on for two or three days. The gelatin may be used as an 
excipient. Gelanthum is an ointment base that does not 
contain lard or oil, and is a good excipient. Medicated 
soaps have their advocates. 

In the treatment of eczema we must not content our- 
selves by simply giving our patient an ointment, but we 
must instruct him in the way he should use it. As a 
rule, and where possible, ointments should not be smeared 
on the skin, but spread on old linen, muslin, or the like, 
and bound down with a bandage or with a ring of elastic 
webbing. In chronic patches it is well to rub in the tar 
or other ointment. 

Massage sometimes does good service in reducing infil- 
tration, the part being stroked upward, in the course of the 
circulation. 

Baths are not usually advisable in eczema, and are 
applicable only to chronic cases. Good results have 
been reported from some sulphur baths. Residence at 
the seaside generally proves bad for eczematous patients, 
but it may be a good thing for some run-down patients, 
the tonic effect of the sea air out-balancing the evil 
effects of the dampness. Soda, borax, or bran baths 
will prove grateful in some cases. Bulkley orders the 
following: 
16 



242 DISEASES OF THE SKIN 



1$ — Potass, carbonat., giv 130 

Sodii carbonat., giij 100 

Boracis pulveris, gij 70 

Add to thirty-gallon bath with half a pound of starch. 



M. 



Crocker recommends counter-irritation over the spine, 
the nape of the neck for eczema of the upper half of the 
body, and over the last dorsal and first lumbar vertebra 
for the lower half. Dry heat, a mustard leaf, or liquor 
epispasticus may be used. The spinal ice-bag sometimes 
accomplishes the same result. 

The x-rays and radium are at times useful in chronic 
thickened, obstinate patches of eczema. They should be 
used with caution by experts only, as they are capable of 
doing much harm. The high-frequency current, D'Arsonval, 
allays the itching and tends to dissipate the patches. It 
may be used two or three times a week, the tube being 
passed over the patch in contact with the skin, or at a 
little distance from it, according to the amount of stimu- 
lation desired, and the ordinary applications continued 
between times. The Kromayer lamp has been used with 
success. 

Prognosis. — We can give assurance of curing most 
cases of eczema as far as the attack with which the patient 
comes to us is concerned. We can give no positive assur- 
ance that the disease will not return. The cure of the 
attack requires patience, careful study of the case, and 
the intelligent use of remedies. But there are some cases 
that are exceedingly rebellious. We have to accept the 
fact that some people are "eczeinatous," and that they 
cannot be permanently cured unless they are regenerated. 
We should cure our cases as rapidly as possible, and not 
take refuge in the excuse of the incompetent man and 
tell the patient that it is dangerous to cure eczema. 

We must now consider Regional Eczema. 

Eczema Ani, as usually met with, is of the squamous, 
thickened variety with fissuring. It may also be moist. 
It usually extends up the whole internal fold. It gives 
rise to great pain in defecation and to much itching at 






ECZEMA 243 

all times. The discharge from this form, as well as from 
eczema of the genitals, is frequently offensive, owing to 
the decomposition of the sebaceous secretions. Excessive 
use of tobacco predisposes to this variety of eczema, 
probably on account of the nervous irritation inducing 
itching, for the relief of which the patient scratches and 
produces the eczema. Other predisposing causes are all 
those that cause pruritus ani, which see. 

Treatment. — The first thing is to stop the use of to- 
bacco, a hard task, as the patient ofttimes is incredulous 
of its efficacy. Horseback-riding and much walking will 
sometimes have to be stopped, as they may aggravate 
the trouble. If hemorrhoids or fissures of the mucous 
membrane are present, as they quite frequently are, 
they must be cured in order to obtain a permanent cure 
of the eczema. The bowels must be kept easy by laxa- 
tives, so that one soft movement may be had each day. 
Liver derangements must be corrected to prevent portal 
congestion, and dieting will be of service. The nates 
must be separated by folds of lint, and the parts kept 
scrupulously clean, though water should be used as spar- 
ingly as possible. Applying 75 to 90 per cent, alcohol 
both cleanses and disinfects the parts, and allays the 
itching. It should be used two or three times a day. 
The itching may be relieved by sopping on hot water, 
dabbing the part dry, and making the chosen application. 
In acute and subacute cases the use of alcohol followed 
by compound stearate of zinc or other dusting powder; 
or oxide of zinc ointment, will prove curative. In more 
chronic cases tar or diachylon ointment may be used 
covered with a dusting powder. Usually the drier the 
parts can be kept and the less ointment is used the 
better. Painting a limited surface with salicylic acid, 
10 to 15 grains (0.66 to 1) in an ounce (32) of flexible 
collodion is often followed by the happiest results. 
Painting with nitrate of silver, 10 to 15 (0.66 to 1) grains 
to the ounce (32), is sometimes advisable. Here, too, 
if there is much thickening, wearing rubber cloth for 



244 DISEASES OF THE SKIN 

a few days or using a salicylic acid plaster will greatly 
hasten the cure. A well-applied T-bandage or bath- 
ing trunks is the best way of keeping the dressing in 
place. Thigenol, 50 per cent, solution in water, often acts 
well. It stops the itching, stimulates the skin, and, as 
it dries on the skin, does away with the use of ointments. 
Liquor carbonis detergens, 10 to 20 per cent, strength, 
sometimes does well. 

Eczema Aurium.— Eczema may affect both the ear 
itself and the inside of the auditory canal. When the 
ear is acutely affected, it is swollen at times so much as 
to stand out from the head. In acute eczema of the 
external auditory canal, which is secondary to that of the 
auricle, the swelling may be so great as to cause dulness 
if not loss of hearing. 

Treatment. — Of eczema of the outer part of the ear 
nothing special need be said excepting that the dressings 
must be exactly applied to all the little furrows of the 
ear, and a pledget of lint placed in the furrow behind 
the ear, thus separating it from the side of the head, so 
that in sleeping the two surfaces of skin do not come 
in contact. Painting this part of the ear with a solution 
of nitrate of silver, 10 grains (0.66) to the ounce (32), 
will sometimes aid greatly in converting a moist eczema 
into a squamous one. A cure will be hastened by having 
the ear covered with a linen bag made in the fashion 
of an ear-muff. Eczema of the auditory canal is some- 
times very annoying on account of an accumulation of 
scales, dulling the hearing. For this condition an oint- 
ment of tannin, 1 drachm (4) to the ounce (32), or a 
solution of nitrate of silver, 5 to 20 grains (0.33 to 1.33) 
to the ounce (32), may be applied throughly by means 
of absorbent cotton on a probe, the ear being properly 
lighted by means of a head-mirror, and the operator 
having the requisite skill. Otherwise the tannic acid 
ointment, or one of the oxide of zinc, or ammoniate 
of mercury, or the diachylon ointment may be applied 
on pledgets of lint rolled up to fit the orifice. It must 



ECZEMA 245 

be remembered that ointments mixed with the exfoliated 
epidermis of the canal, and forming a paste with it, tend 
to stop up the canal and produce deafness. Such deaf- 
ness can be removed by syringing, or mopping with oiled 
cotton. The insufflation of boric acid will sometimes be 
better yet. The ear should not be syringed out often, 
and when it is necessary to do so a solution of borax or 
baking soda should be used. 

Eczema Barbae is scarcely ever confined to the bearded 
portion of the face, but it generally runs over onto the 
bordering skin, and is often but a part of eczema of the 
face. It has practically the same symptoms as has 
eczema capitis. It needs to be diagnosed from ring- 
worm and sycosis, which see. In treatment, shaving, or 
cutting the hair close, which is better, should be practised 
so that remedies may be closely applied. Plucking the 
hair from the pustules is to be recommended. Its further 
treatment is the same as that of eczema capitis. It is an 
obstinate form of eczema, prone to relapse. 

Eczema Capitis. — The scalp is very commonly the seat 
of eczema, either by itself or in connection with eczema 
elsewhere. It has received various names, such as crusta 
lactea; porrigo; melitagra; scalled head; milk crust; 
or vesicular or running scall. While any variety of 
eczema may occur on the scalp, the vesicular is very 
rarely seen, and the most common is the pustular and 
the final stage, the squamous. In the acute stage the 
scalp may be swollen and boggy, and moist, with the 
hair stuck together. We may find the scalp crusted 
with a yellowish serous crust, but more commonly there 
is a greenish or blackish purulent crust, while the scalp 
is swollen but little. In some cases of pustular eczema 
there will be discrete, rather large pustules scattered 
through the hair, besides moist and crusted patches. 
The hair is always matted together, and the odor from 
the scalp is unpleasant. If the crusts are removed, they 
will soon reform. 

In both the erythematous and the squamous forms the 



246 DISEASES OF THE SKIN 

scalp is red and scaly. There is apt to be more or less 
thickening of the scalp, and in very severe cases the 
scalp may be cracked. Not infrequently there will be 
squamous patches in some places and moist and crusted 
patches in other places. 

With eczema of the scalp there is almost always 
eczema behind the ears. The cervical glands are very 
often swollen, especially in children, but they need 
give no anxiety, as they very rarely suppurate. In 
the chronic form there may be loss of hair, especially 
in children, when it is sometimes mechanically rubbed 
off from the occiput. It is never permanently lost. All 
forms are itchy, the pustular form least so. The patient 
may complain of a "drawn" feeling of the scalp. As 
in all inflammatory disease of the scalp, there is over- 
activity of the sebaceous glands, and the crusts will con- 
tain a certain amount of fat. In chronic cases there 
may be, on the other hand, a deficiency of fat. Pediculi 
are often found on the hair. The disease may affect the 
whole scalp or only a portion of it, and may run an 
acute or chronic course. 

Etiology. — The exciting causes of eczema capitis are 
all irritants to the scalp. Sometimes it is well-meant, but 
badly directed efforts at cleanliness, especially in children, 
who are more often subjects of this form of eczema than 
are adults. Combing with a fine-toothed comb, too 
vigorous use of soap and water, the use of a too stiff 
brush, are some of these. Pediculi are very often the 
cause — not the pediculi themselves, but the scratching 
to relieve the itching produced by them. An eczema of 
the occiput should always suggest their presence, and 
search then will generally reveal the pediculi, or their 
nits upon the hair. Sometimes remedies used to kill 
lice will set up an eczema, such as strong mercurial 
ointments. Too strong hair lotions and hair dyes not 
infrequently cause eczema. In most cases eczema of the 
scalp is but a part of a more or less general eczema and 
due to the same causes. 



ECZEMA 247 

Diagnosis. — The disease must be differentiated from 
pityriasis capitis, ringworm, erysipelas, lupus erythemato- 
sus, a dermatitis, psoriasis, seborrhea, favus, pediculosis, 
and syphilis. See under these diseases. 

Treatment. — The treatment of eczema capitis is along 
the same lines as is that of the disease in general. On 
the scalp it is always best to use our remedies either in 
vaselin or oil, as preparations of lard make a disagreeable 
mess with the hair. Nor should a thick ointment ever 
be used, excepting perhaps in children before their hair 
is grown, or on bald heads. If there are crusts on the 
scalp, they must be removed before any local treatment is 
used. This may be done best by soaking them with sweet 
oil containing 1 or 2 per cent, of salicylic acid for twelve 
or twenty-four hours, and then washing them away with 
soap and water. Plenty of oil must be used, and it is well 
to tie the head up in a towel overnight. A woman's or 
half-grown girl's hair should never be cut in order to treat 
the scalp. In applying remedies to the scalp, after the 
acute stage, they should be rubbed in, and not merely 
smeared over it. 

In acute eczema equal parts of lime-water and sweet or 
almond oil, with or without 1 or 2 per cent, of salicylic 
acid, or carbolic acid, form a good application. Black 
ivash, or a weak ammoniate of mercury may be used. 

In subacute and chronic eczema of the scalp, tar, espe- 
cially the oil of cade, is our most reliable remedy. It 
must be remembered that it can be used much earlier on 
the scalp than elsewhere, and most cases will improve 
under it as soon as the acute stage is passed. It may be 
begun in the strength of 20 drops (1.33) to the ounce 
(32) of oil, and increased to 1 or 2 drachms (4 to 8) to 
the ounce (32). Many people object to the odor of the 
tar. We can substitute for it: 



Or, 



1$ — Hydrarg. ammon., 
Vaselini, 


gr. xx 1 1 33 
ad gj ad 32 1 M. 


R — Ac. salicylici, 
01. olivse, 


gr. xx-xxx 1.33-2 
ad 5J ad 32 M. 



248 DISEASES OF THE SKIN 

The oil of cajuput in 5 to 10 per cent, strength may 
be tried. Neither of these is as good as tar. 

If the disease is in a chronic condition, shampooing 
with green soap or its tincture, followed by some oily, not 
very stimulating application, will prove curative. In this 
connection it is sometimes best to exhibit the tar in an 
alcoholic solution. Resorcin in 3 to 10 per cent, strength 
may be used cautiously in this way. In very obstinate 
cases precipitated sulphur 10 to 40 grains (0.66 to 2.66) 
to the ounce (32) of olive oil or albolene at times is 
excellent. It will do either good or harm. If the scalp 
is cracked and thickened, great and prompt amelioration 
will be secured by having the patient wear a close-fitting 
cap of rubber. 

Eczema Crurum. — Eczema of the legs acquires its 
peculiarities from the fact that the circulation of the 
parts is less active than it is in the upper portions of 
the body, on account of the action of gravity upon the 
returning venous blood. Any form of eczema may be 
present. Varicose veins, either superficial or deep, pre- 
dispose to it; and an eczema arising from such a cause 
is spoken of as varicose eczema. It is attended with 
swelling and often great oedema. It is located principally 
on the lower part of the leg, and is often complicated 
by ulceration. Pigmentation of more or less dark-brown 
color follows or accompanies it, if of any chronicity, and 
occasionally purpuric spots will be scattered about the 
chronic patch. As to treatment, nothing special need be 
said except that it is always advisable to have the legs 
bandaged snugly from the toes to the knee, and that the 
best result will be attained when the bandaging is done 
by the doctor or a trained nurse. 

Eczema Genitalium often causes a great deal of discom- 
fort on account of the excessive itching that accompanies 
it. It affects the scrotum most commonly, which in 
some cases will be greatly thickened and feel like leather. 
The skin of the penis also suffers at times as well as the 
glans. In women, both the lesser and the greater lips 
of the vulva, as well as the entrance to the vagina, may 



ECZEMA 249 

be affected, and show excoriations and thickening. All 
forms of eczema may be encountered in the genital 
region. In chronic eczema of the penis the organ be- 
comes greatly enlarged both laterally and longitudinally, 
on account of the thickening of the skin. The disease 
may be confined to the genitals, or extend to the thighs 
or the anal region. The presence of diabetes should 
always be suspected in a case of this kind, and the urine 
should be examined for sugar. Leucorrhea is a common 
cause of the disease in women. 

Treatment. — In the treatment of eczema of the 
scrotum, apart from that appropriate to general con- 
ditions and especially to diabetes, it is essential that one 
should wear a well-fitting suspensory bandage, inside of 
which the dressing may be placed. The itching may be 
greatly relieved in all forms by directing the patient 
to sit over a vessel containing hot water and sop the 
water up on the parts. The application of 75 to 90 per 
cent, alcohol will allay the itching, and keep the parts 
disinfected. It may sting for a few minutes. In sub- 
acute eczema the skin should be mopped dry, the oxide of 
zinc ointment, diachylon ointment, or Lassar's paste imme- 
diately applied, and the suspensory bandage adjusted. 
Carbolic acid, 1 or 2 drachms (4 to 8) to the ounce (32) 
of glycerin and water, may also be used, lightly dabbed 
on, for the purpose of allaying the itching. It should be 
used twice a day. For chronic, thickened eczema, wearing 
sheet rubber inside of the suspensory bandage will give 
positive and immediate relief, and greatly reduce the 
thickening. After a few days it is well to follow it with a 
tar or resorcin ointment. The use of the tincture of 
tar, as spoken of under chronic eczema (page 237), is 
often most serviceable. In some cases nothing will do 
so well as the application of the nitrate of silver solution, 
already given. The spirit of nitrous ether may be used 
as an excipient of this. Hardaway speaks highly of 
rubbing the scrotum with a solution of salicylic acid in 
alcohol, 1 drachm (4) to the ounce (32), and following 
this with a boric acid or diachylon ointment. 



250 DISEASES OF THE SKIN 

Women should use a T-bandage instead of a suspen- 
sory. Otherwise the treatment is the same. In them 
the nitrate of silver treatment at times does remarkably 
well. 

Eczema Intertrigo occurs wherever folds of skin come 
in contact. It usually follows a simple intertrigo, dif- 
fering from it in having a discharge that stiffens linen, 
and in its pruritus. In its treatment the parts should 
be kept separated and as dry as possible by means of a 
dusting powder, or by placing a piece of old linen or 
cheese-cloth between the apposed folds of skin. For a 
dusting powder we may use corn starch either alone 
or with bismuth or zinc oxide; lycopodium is also an 
excellent powder; but the best powder of all is the com- 
pound stearate of zinc. Before any application is made 
it is best to wipe the skin off with 75 to 90 per cent, 
alcohol, or, if it smarts too much, a saturated solution 
of boric acid. As a rule, these cases do best without 
ointments. This does not apply to eczema intertrigo 
of the crotch. Here it is well to cover the parts with a 
greasy application, so as to protect them from the action 
of the urine. A dilute diachylon ointment often answers 
admirably. In chronic conditions the same stimulants 
should be used as in any other chronic eczema. 

Eczema Labiorum is usually due to nasal catarrh, and 
can be cured only when the cause is removed. Eczema 
may occur about the mouth in an orbicular manner. 
Many people suffer from chapped lips, especially in 
winter. This is an eczema of the vermilion border. For 
this little can be done except to caution the patient 
against moistening the lips. Greasing the lips every 
night with camphor-ice or the like keeps them in good 
condition. Glycerin agrees well with some skins, and is 
harmful to others. The lip may be painted with com- 
pound tincture of benzoin. Eucerin is a most efficacious 
application. 

Eczema Mammarum et Mammillarum. — One of the 
most annoying accidents to befall a nursing woman is 
eczema of the nipples. They become excoriated and 



ECZEMA 251 

fissured, the cracks sometimes extending to the base of 
the nipple. At times a drop of pus can be squeezed 
from the bottom of the crack. They are exquisitely 
sensitive, and every time the baby nurses the woman 
suffers agony. The moisture of the child's mouth and 
the decomposing milk left on the nipple aggravate the 
trouble. Mastitis may complicate matters. In the 
intervals of nursing the nipple scabs over. Either one 
or both nipples may be affected. The disease may 
extend onto the breasts, or the breasts may be affected 
independently of the nipples. Women with pendulous 
and heavy breasts frequently suffer with a moist eczema 
in the sulcus beneath them. Apart from this, nothing 
special need be said about eczema of the breasts. There 
is one disease of the breasts called Paget's disease of the 
nipple, which at first very closely resembles eczema. (See 
Paget's Disease, for diagnosis.) 

Treatment. — It is often possible to cure eczema of 
the nipples even while the child nurses. Sometimes it 
will be necesary to wean the child. Women during the 
latter months of pregnancy should handle their nipples 
every day and bathe them with alcohol, to which may 
be added 20 or 30 grains (1.33 to 2) of borax to the ounce 
(32) . This will do much to prevent further trouble. The 
suckling having begun, the nipples should be carefully 
washed off and dried with a soft handkerchief after each 
nursing, and dressed with oxide of zinc or diachylon oint- 
ment should eczema show itself. Of course, the ointment 
should be removed before the infant is put to the breast, 
and this should be done with as little water and as much 
gentleness as possible. If there are cracks, the child 
should nurse through a rubber nipple, and when it lets 
go the nipple should be dried and painted with compound 
tincture of benzoin, or the solution of nitrate of silver 
already spoken of. It is also advised to touch the cracks 
with the nitrate of silver stick. This is very painful, 
and of little use as long as the infiltration of the nipple 
that causes them continues. The nipples may be washed 
with a borax solution and covered with an ointment of 



252 DISEASES OF THE SKIN 

boric acid. It is always advisable to use nothing that 
is poisonous in the dressings. Hardaway recommends 
the following for eczema under the breasts: 

I*— Thymol., gr. j 065 

Pulv. zinci oleat., gj 32| M. 

Eczema Manuum. — Eczema of the hands has been 
called "washerwoman's itch/' "grocer's itch," "brick- 
layer's itch," and various other itches. It is in many 
cases a trade eczema, caused by strong alkaline soaps, or 
contact with sugar, mortar, or other irritant, .such as 
bichloride solutions, formalin, and the like, and might 
better be considered as a dermatitis. It may arise 
independently of any of these trade causes, or it may 
be part of a general eczema. The acute forms, as they 
occur upon the back of the hands, do not differ from the 
same on other parts of the body, and the same may be 
said of the chronic forms. The palms are seldom prim- 
arily affected, but secondarily to eczema of the wrists 
or fingers. The epidermis of the palms, as well as that 
of the palmar surfaces of the fingers, is thicker than that 
of the other parts of the body, excepting the soles 'of 
the feet, and so the vesicles do not rupture readily, but 
are seen like little, more or less translucent grains under 
the skin. When they rupture, the skin is left more or 
less ragged and worm-eaten. The skin over all the 
joints is liable to crack and form painful fissures. Chronic 
eczema of the palms prevents free movement of them 
on account of the thickening and the painful cracking. 
The skin is reddened and covered with large adherent 
scales. Itching is intense at times. The whole palm may 
be affected, or the disease may form limited areas, as 
upon the centre of the palm, over the thenar eminence, 
and upon the finger ends. This form of eczema is often 
difficult of diagnosis from the squamous syphilid. The 
occurrence of the lesions upon one hand alone should 
arouse suspicion of syphilis, especially if little or no 
itching is complained of. 



ECZEMA 253 

Treatment. — Eczema of the palms is one of the 
most obstinate of eczemas to treat when of chronic 
form; and requires active stimulation by means of tar; 
salicylic acid; the soap and salve treatment; rubbing in 
5 to 10 per cent, of the oleate of mercury; or painting 
with caustic potash. Veiel 1 recommends the use of a 
1 to 6 per cent, ointment of salicylate of mercury in 
simple ointment, a bandage being worn at night. After 
the eczema is cured he advises using twice a day after 
washing and while the hands are wet, Potassa 30 grains 
(2), Alcohol, aquse rosse, and glycerin aa p.e. ad § iij (100). 

The constant wearing of rubber gloves is excellent 
for the purpose of softening the skin and preparing it 
for other remedies. It is best to use the canvas-lined 
gloves, turn them inside out, and wear the rubber next 
the skin. The hands must be kept out of water. Where 
this cannot be done, great care must be used in drying 
them. It is well to have the patient dry on two towels 
or before the fire, and then either to thrust the hands in a 
box of corn starch powder or flour, or preferably to apply 
the proper dressings. * 

Eczema of the back of the hands is treated the same as 
an eczema elsewhere. Unna teaches that eczema of the 
hands and fingers is always secondary to eczema sebor- 
rhoicum capitis. He recommends in the disease, as it 
affects cooks, housemaids, and the like, that the hands, 
on going to bed, should be washed with green soap and 
water when the eczema is of squamous form, and with a 
weaker soap when it is moist. Then a paste of 

Oxide of zinc, 40 parts. 

Chalk, 

Lead-water, 

Linseed oil, aa, 20 parts. 

or one of 

Oxide of zinc, 

Sulphur, 

Chalk, 

Linseed oil, 

Lime-water, aa 20 parts. 

i Arch. Derm. u. Syph., 1912, cxiii, 1181. 



254 DISEASES OF THE SKIN 

is to be well rubbed in. Before using the paste, when 
the eczema is moist, the patch should be powdered with 
flour. The paste is covered with the thinnest rubber 
tissue, such as is used for bouquet handles. This will 
stick well. Cotton gloves can be worn at night. In 
the morning the dressing is not to be removed until the 
roughest part of the work is done. Then it is to be 
washed off, and a little of the paste applied until time 
for the evening dressing. 

In eczema of the hands of masons, washerwomen, and 
the like, an endeavor should be made to thicken the 
corneous layer of the skin by dressing them at night 
with a paste of 

Resorcin, 

Ungt. zinci oxid., aa 10 parts. 

Terrae silicse, 2 parts. 

and applying oil or vaselin over it. In the morning the 
hands are not to be washed, but anointed with some oil. 
After a time the corneous layer thickens and the old skin 
falls off. Eczema of the hands due to occupation becomes 
rapidly well when the patient no longer follows his trade. 
It is sometimes necessary to seek some other occupation. 
Hospital nurses are often much troubled in this way, 
and have to give up nursing. 

Eczema Narium is often, if not always, associated with 
a chronic rhinitis. It is very obstinate. Crusts form on 
the inside of the nose, are picked off, re-form, and after 
a time ulcers may result from the constant irritation. 
Sometimes in adults the disease locates itself about 
the hair follicles, and is very annoying. It is a not 
uncommon point of departure for recurrent attacks of 
facial erysipelas. If long continued, it gives rise to a 
thickening of the upper lip. Furuncles sometimes 
complicate matters. 

In the treatment of these cases the first attention must 
be given to the cure of the rhinitis. Then all crusts 



ECZEMA 255 

must be removed by soaking with oil. For the eczema 
we may use: 

1$ — Glycerol, plumbi subacetat., 

Ungt. aquae rosae, aa p. e. M. 

as recommended by Hardaway. 

Herzog 1 recommends the yellow oxide of mercury 
ointment, or equal parts of ungt. plumbi and vaselin, 
spread on lint and accurately applied to the diseased 
part. Unna rolls his zinc and red precipitate ointment 
muslin into a pledget and introduces it into the nose. In 
obstinate cases about the hairs epilation by electrolysis 
may have to be performed. 

Eczema palpebrarum is usually of an erythematous 
character, and occurs as part of the same disease else- 
where. Eczema of the cilia, also called blepharitis 
ciliaris, is always pustular. The edges of the lids are 
swollen, rounded, and more or less thickly strewed with 
pustules or crusts. The lids stick together on waking 
in the morning. In the squamous form the edges of the 
lids are merely red and scaly. It is almost always sym- 
metrical, occurs usually in strumous subjects, and is due 
to conjunctivitis. 

Treatment. — The lids should be anointed before 
going to sleep, in order to prevent their sticking to- 
gether. We have always found the following ointment, 
as given by Prof. D. Webster, of the New York Poly- 
clinic, most excellent: 



R; — Ac. salicylici, gr. x 

Ungt. hydrarg. oxid. rubri, 3j 4 

Ungt. aquae rosae, 3vj ad 24 



66 
M. 



An ointment composed of 



R; — Hydrarg. oxid. flav., gr. ij-viij 0113-5 

Vaselini, §j ad 32 j M. 

is recommended by Hardaway. Resorcin, gr. iij in cold 
cream, oiiss, is editorially commended in the Monatshefte 

» Arch. f. Kinderheilkunde, 1887, p. 211, 



256 DISEASES OF THE SKIN 

f. prakt. Dermal., 1888, vii., 1057. Whatever is used, 
we must be sure that any substance entering into it is 
in an impalpable powder, so as to avoid the possibility 
of getting anything gritty into the eye. Epilation may 
be necessary in some cases. Solutions of bichloride of 
mercury (0.05 to 500) are commended, both for the con- 
junctivitis and the eczema dependent upon it. In any 
event, the conjunctivitis must be treated. 

Eczema Pedum. — Eczema of the soles of the feet, though 
not so common as that of the palms, presents the same 
symptoms and calls for the same treatment. The greatest 
difficulty will be encountered in dressing the toes properly. 
For this the ointment should be spread upon a long and 
narrow strip of lint, the centre of the strip placed against 
the big toe, and the strip wound in and out between the 
toes. A piece of salve-muslin may be substituted for this 
with advantage. A piece of rubber sheeting cut to fit the 
sole and bound down with a bandage takes the place of 
the rubber glove. 

Eczema Unguium. -^-Eczema may affect the nail fold 
alone, and the mail may be scarcely diseased; or the matrix 
and bed may be diseased, when the nail will lose its 
luster, and become round, uneven, striated, and atrophied. 
Only one nail may be diseased, or all of them may be. 
The nail may be depressed in the centre and turned up 
at the end, with an accumulation of scales under its free 
border. Usually eczema of the nails occurs as a part of 
a general eczema, but it may occur as an independent 
disease. The fleshy parts about the nails usually present 
signs of inflammation, and often of an evident eczema. 

It is best treated by means of cots made of rubber. It 
must be remembered that an ointment can never be used 
when rubber is, as the grease rots it. If the time has come 
for an ointment, linen or leather cots must be substituted 
for the rubber ones. The ointment to be used will depend 
upon the condition of the skin about the nails. Strapping 
the nails with a 10 per cent, salicylic acid plaster is often 
most satisfactory. 



ECZEMA INFANTILE 257 

Universal Eczema is uncommon, and when it does occur 
it is usually of the erythematous or squamous variety, 
with a tendency to cracking in the skin creases of the 
joints, exudation, scaling, and itching. These symptoms 
will serve to distinguish it from dermatitis exfoliativa, to 
which it bears a strong resemblance. Constitutional dis- 
turbances, such as fever and chills, loss of appetite, and 
digestive disorders, are not uncommon in these truly 
pitiable cases. Furunculosis is apt to complicate matters. 
The patients are slow in recovering, and are apt to be a 
good deal pulled down by the disease. 

Treatment.— These patients should be put to bed and 
the underlying cause searched for, and if possible removed. 
They are best treated locally by lotions, oils, or vaselin. 
The ordinary Carron oil, equal parts of linseed oil and 
lime-water; cotton-seed oil with carbolic acid, 1 part of 
acid to 60 of oil; or simply smearing the body with 
vaselin and powdering on corn starch, will each relieve. 
Salicylic acid in oil, 1 in 30, will also allay the discomfort, 
but it sometimes causes symptoms of constitutional 
poisoning, and has to be stopped. Alkaline or bran 
baths, warm, followed by one of the above, after tapping 
the skin gently dry, will also relieve, but the bath should 
not be used more than once a day. Its temperature should 
be about 90° F. ; it should last ten to fifteen minutes. 
Bulkley recommends anointing the skin, before drying it, 
with — 

R— Acid, carbolic! , gr. xx-5ij 1—6 1 

Glycerit. amyli, ad §iv ad 100 1 M. 

applying it freely. The best way of drying the skin is 
to envelop the patient in a warm sheet, and pat the skin 
dry. As the intensity of the eczema lessens, the frequency 
of the baths must be reduced. The disease will gradually 
become localized in patches. 

Eczema Infantile presents certain peculiarities that war- 
rant its being considered as a special variety of eczema. 
It is very prone to be of the pustular form, following the 
17 



258 DISEASES OF THE SKIN 

rule that in delicate or debilitated subjects an eruption 
upon the skin is apt to be pustular. While in adults 
eczema of the face is usually erythematous, in infants it 
is nearly always pustular. In them it is quite common, 
if not the rule, to have several regions affected at once, 
such as the scalp, the face, and the region of the crotch. 
In them, also, eczema madidans often occurs in these 
regions. While in adults that form of eczema is most 
frequently seen upon the legs; in infants it is quite excep- 
tional there. Eczema of the scalp in infants presents 
itself as a thick crust formed of purulent matter, epithe- 
lial debris and sebaceous matter. This is called a milk 
crust." When the crust is raised the scalp will be found 
to be thickened, swollen, boggy, and moist, with a puru- 
lent secretion. The whole scalp may be affected, or only 
the vertex. With it there will nearly always be a moist 
surface behind the ears, even though the face may be 
comparatively or absolutely free. The lymphatic glands 
will be swollen, but they seldom suppurate. When the 
face is affected it will sometimes be studded over with 
holes, superficial ulcerations, which, however, never leave 
scars. This appearance is seen very rarely in adults. It 
is often striking to note that the skin about the mouth 
and nose, and below the eyes, is in perfect health, though 
pale, while all the rest of the face may be involved in 
the moist intense inflammation. 

The creases of the neck, the flexures of the joints, 
and the region of the genitals usually show an erythem- 
atous or a moist intertriginous eczema. At times the 
whole body will be affected with a general, but very 
rarely with a universal eczema. While the pustular and 
intertriginous forms of eczema are the most common, 
we may have all forms present at one time. The papular 
form is also frequently met with alone. Itching is usually 
severe, keeping the little patient awake at night, and 
the tearing made by the nails to relieve the itching gives 
rise to immense excoriations, especially of the face. 
Unrelieved, the little patients sometimes become pitiable 



ECZEMA INFANTILE 259 

objects on account of loss of sleep and constant nervous 
excitement. 

Etiology. — There are several causes tending to pro- 
duce eczema in infants. Their skin is vulnerable to all 
irritants. More than one-third of the cases of eczema 
occurring before the fifth year of life occur in the first 
year. Add to the vulnerability of the skin the over- 
zealous care as to cleanliness commonly bestowed upon 
it for a few months after birth, and we have a good 
explanation for its frequence. Bad diet has much to do 
with its production. The vast majority of the little 
sufferers are nursed too often if at the breast, "every 
time they cry" being the rule; or fed too frequently or 
improperly, " everything that is going" being again the 
rule. Inattention to the condition of the diapers is 
another active cause of eczema about the genitals. 
Teething is, without doubt, an exciting cause, a fresh 
outbreak of eczema marking the eruption of each tooth. 
Want of self-control in scratching is an aggravating 
circumstance. The frequent disturbances of digestion 
so common at this period of life predispose the infant's 
skin to eczema with rather more force than do the same 
troubles in adults. Fat babies are frequent subjects of 
eczema, especially of the intertriginous variety. 

Treatment. — The treatment of eczema infantile is 
along the same lines as that of eczema in adults. Special 
stress must be laid upon the feeding of infants, and strict 
rules must be laid down for the parent's guidance. The 
condition of the breast milk must be inquired into, as it 
is often of too poor quality to nourish the child. Women 
will sometimes nurse their children far too long, with the 
idea of preventing conception. If the child is bottle-fed, 
the quality of the milk must be investigated, and it, as 
well as the amount, regulated. 

It is very necessary to insist upon the. child wearing 
a mask in eczema of the face and scalp. This may 
be made of light flannel or muslin, a piece of the 
stuff being cut somewhat after the shape of the face, 



260 DISEASES OF THE SKIN 

with holes made for the nose, eyes, and mouth. A 
skull-cap is to be made, on to which the mask may be 
sewed, or pinned with safety pins. The ointment is to 
be spread upon lint, cheese cloth, or washed muslin— 
a strip for the forehead, one for the chin, and one for 
each cheek. These are to be laid upon the face, and then 
the mask put over them, fastened to the skull-cap, and 
tied behind the head by two strings from its lower corners. 
It is astonishing what relief this affords to the itching, 
and how much more rapidly the case improves under it. 
As it is impracticable to use the mask in public practice, 
Unna's paste made of 

1$ — Oxide of zinc, 40 parts. 

Chalk, 
Lead-water, 
Linseed oil, aa 20 parts. M. 

may be used as a substitute. In making, the first two 
ingredients are to be mixed together, and then the last 
two, and then the two parts thus formed. It is to be 
spread on the part, and cannot be readily rubbed off, 
though it can be easily removed with a little oil. 

The itching of the skin can be relieved by appropriate 
dressings, and it is never necessary to put the child in a 
home-made strait-jacket, by slipping it into a pillow- 
case and sewing up the same between the arms and body. 
This is an extreme measure. In eczema of the crotch 
great care must be given to changing the napkins as soon 
as soiled. Fresh, clean ones must be put on, not those 
that have been dried without being washed. Dr. George 
H. Fox has called attention to a tight prepuce as a cause 
of eczema in male children. The urine dribbles away, so 
that a few drops wet the clean diapers, and thus keep up 
the trouble. In such cases judicious stretching of the 
prepuce may obviate the necessity for circumcision. 
Water must be kept from the skin in all acute cases. 

Internally, calomel in tablet triturates, T V grain, three 
times a day for three days, will give good results in 
many cases, especially in fat babies, even though the 



ECZEMA MARGINATUM 261 

bowels are not constipated. After an interval of three 
days the calomel is to be given again. Care must be 
taken not to produce too frequent and loose movements 
of the bowels. The rhubarb and soda mixture is excel- 
lent in many cases. Other medication will be necessary 
according to the nature of the case. Cod-liver oil w r ill 
often cure a case which has been very obstinate. The 
local treatment is, according to the rules, already given 
under Eczema. 

Eczema Marginatum. — Until 1911 this disease was 
called tinea cruris and was thought by most authorities 
to be due to ringworm. By others it was considered 
as an ordinary eczema occurring in the skin folds, espe- 
cially about the crotch, which was peculiar in having a 
sharp margin. Sabouraud in 1907 found that it was 
caused by a special form of fungus that he called epi- 
dermophyton inguinale. S. Nicolau 1 has given the best 
account of the disease. 

Symptoms. — Its special site is the inguino-cruro- 
scrotal fold. It begins always at the bottom of the fold 
from where it spreads upward, and in long standing 
cases backward into the anal fold, and upwards onto the 
pubes. It takes the form of red or brownish marginated 
circles covered with delicate scales, which are sometimes 
so fine as to be hardly appreciable to the eye. In fully 
developed cases the patch will end on the inside of the 
thigh and the scrotum with a sharp festooned margin. 
In some cases the patch is eczematous in appearance. 
It occurs in all the skin folds, and at times there will be 
ring-shaped patches on other parts of the body. 

One peculiarity of the disease is that it occurs between 
the toes and fingers, especially the former. In these 
locations it has been thought to be eczema. It affects 
principally, according to Sabouraud, 2 the interdigital 
fold of the fourth and fifth toes. At the bottom of the 
fold there is a collection of white, cheesy substance which 

1 Annal. derm, et syph., 1913, iv, 65. 2 Ibid., 1910, i, 289. 



262 



DISEASES OF THE SKIN 



is readily scraped away. Under it the skin is white, 
shiny, moist, and macerated, and very much thickened, 
so that it may be scraped off in large patches. About the 
fold are a few isolated vesicles that dry up and are re- 
placed by new ones. The plantar surface of the foot 
is not affected, but the disease may spread on the back 

Fig. 27 




Eczema marginatum. 1 



of the foot as a sharply defined dry eczematous patch. 
The disease itches, and causes pain on walking. The 
hands are rarely affected and then the appearances are 
those of eczema or dyshydrosis. The affection of the 
feet and hands is secondary to the disease in the inguinal 

1 Courtesy of Dr. H. Fox. 



ECZEMATOID DERMATITIS 263 

fold with rare exceptions. Untreated the disease may 
last for years. 

Etiology. — It occurs more often in males than in 
females, and though it is doubtless contagious, the source 
can be traced but rarely. Cases have been reported in 
husbands and wives and their children. Most patients 
are between fifteen and forty years of age. A case has 
been reported in a child, and a few cases in persons' over 
fifty years old. Most persons are in comfortable circum- 
stances and cleanly. The epidermophyton inguinale is 
the cause of the disease. It presents innumerable myce- 
lial threads about 2/jl in diameter, sometimes running at 
right angles, and sometimes sinuous. Usually they are 
in the form of ribbons composed of cells of equal size. 
These may be of unequal size, ovoid or rounded. They 
have double contours. 

Treatment. — An ointment of 1 per cent, chrysarobin, 
a lotion containing 1 drachm (4) of chrysarobin to 1 ounce 
(32) of equal parts of chloroform, alcohol, and acetone; or 
15 grains (1) of salicylic acid in vaselin 3ij (8) an d 
cocoanut oil to make § j (32) will cure the disease. When 
it occurs between the fingers and toes, the macerated 
skin should be scraped away, and the part treated either 
with tincture of iodin diluted one-tenth, or a weak 
solution of nitrate of silver, or a chrysarobin ointment 
of 1 per cent., which in obstinate cases may be increased 
to 3 per cent, combined with 3 per cent, of salicylic 
acid. If the chrysarobin is not well borne a strong 
mercurial ointment may be used. 

Eczema Seborrhoicum. — See Dermatitis seborrhoica. 

Eczematoid Dermatitis.— This name was given by M. 
F. Engman 1 to. an eczimatoid inflammation of the skin 
secondary to some injury, such as a scratch, an insect 
bite, an ulceration, and the like. It begins about the 
point of injury as an eruption of vesicles or pustules, 

1 Amer. Med. : 1902, iv, 769. 



264 DISEASES OF THE SKIN 

and forms a red, scaly, weeping, or crusted lesion. These 
may coalesce or independently spread to form patches 
that resemble eczema rubrum. In bad cases the dis- 
ease spreads rapidly as a freely discharging surface with 
sharply defined, irregular border. This is undermined 
with seropurulent discharge, becomes denuded of epi- 
dermis, and in a few days or weeks more or less large 
areas are converted into raw surfaces covered with a 
sticky, purulent discharge which oozes from many points 
and dries into crusts. The patch may heal to break down 
again. The disease itches but little. 

The neighboring lymphatic glands may be enlarged. 
The disease is inoculable. It may run a chronic course 
for years. So-called varicose eczema is usually of this 
type of disease. It is a staphylococcic infection most 
commonly, though other forms of bacteria are found in 
some cases. 

Engman has found that a sulphur paste combined with 
cleanliness and bandaging is curative. 

Elephantiasis. — Synonyms: Barbadoes leg; Cochin- 
China leg; Glandular disease of Barbadoes; Sarcocele 
of the Egyptians: Tropical big-leg; Bucnemia tropica; 
Morbus elephas; Pachydermia; Spargosis; Phlegmasia 
Malabarica; Hernia carnosa; Elephantiasis Indica seu 
Arabum. 

A chronic endemic or sporadic disease of the skin, 
characterized by hyperplasia of the skin and subcutane- 
ous tissues, due to a stoppage of the lymphatic or venous 
circulation, especially the former, affecting chiefly the 
lower extremities, and marked by enormous enlargement 
of the affected part. 

Symptoms. — In certain tropical regions, such as India, 
China, Japan, Egypt, Arabia, the West Indies, and South 
America, the disease is endemic; but sporadic cases occur 
in all parts of the world. In the endemic variety there is 
usually what is called "elephantoid fever," with lumbar 
pain, nausea, and vomiting, followed by sweating. The 



ELEPHANTIASIS 



265 



fever is of high grade, and bears a striking resemblance 
to malarial pyrexia. In sporadic cases the characteristic 
fever is wanting, though usually there is some constitu- 
tional disturbance preceding the local symptoms. In 
other instances the fever is altogether wanting. 

Fig. 28 




Elephantiasis. (After Taylor.) 



Locally the affected part at first is attacked apparently 
by erysipelas, or a deep dermatitis, phlebitis, or lymphan- 
gitis; it becomes greatly reddened and swollen; and there 
may or may not be a clear or milky discharge from the 
skin, and an eruption of vesicles. After a time these 
symptoms subside, but the part does not return to its 
normal size, and there is some pitting of the skin on 



266 DISEASES OF THE SKIN 

pressure. After a few weeks or months there is a repe- 
tition of t,he attack, and the part is left still more enlarged. 
And so the case progresses with varying periods of qui- 
escence, and recurrent erysipelatous attacks, each one 
leaving the part more thickened than before, until it 
attains enormous proportions. The normal contour 
of the part is lost; the folds of the skin are obliterated, 
the surface is smooth and shiny, and the color grows 
darker, even blackish. Now no impression can be made 
upon the swelling by pressure of the finger. Ulcerations 
are apt to occur, and some cases show varicose lymphatics 
which are tender and painful, and may rupture of them- 
selves or by accident and discharge a clear or milky 
chylous, coagulable fluid. The escape of this fluid saps 
the patient's strength. 

The parts most frequently affected are the legs, usually 
one, but may be both; and next to them, the male or 
female genitals. It occurs also on the arms, face, ears, 
female breast, and tongue. When the leg is the seat of 
the disease it becomes so large as to interfere with locomo- 
tion and compels the sufferer to take to his bed. The 
surface of the limb may be smooth; or uneven on account 
of the varicose lymphatics; or warty on account of 
enlargement of the papilla?. The foot and leg may melt 
into each other, as it were, all trace of the ankle being- 
lost. Wherever there are two surfaces in contact there 
is apt to be a decomposition of the sweat, sebaceous 
matter, and epithelium, giving rise to a foul odor, like, 
but worse than, that of an ordinary intertrigo. The 
lymphatic glands in the groin are enlarged. Eczema may 
develop with its attendant itching. The appearance of 
this elephantine leg gave the name to the disease. When 
the scrotum is the affected part, vomiting often occurs 
in the febrile attacks, as well as pain in the groins, along 
the spermatic cord, and in the testicles. Hydrocele may 
develop, and the abdominal rings, overstretched by the 
swollen cords, may give opportunity to the formation 
of hernia upon the subsidence of the acute symptoms. 



ELEPHANTIASIS 267 

The scrotum may become so large as to reach the ground 
when the patient is standing, and one case has been 
reported in which it weighed one hundred and ten pounds. 
One form of the affection is called "lymph scrotum or 
nevoid elephantiasis," on account of the marked dilata- 
tion of the lymphatics. 

There are all degrees of thickening of the skin and 
subcutaneous tissues, but the recurrent attacks of erysipe- 
las and the progressive enlargement are characteristic 
of all. The bones may become enlarged. This is a 
very rare affection, which is called "acromegaly." In 
the Lancet of June 11, 1887, several cases are reported, 
one of which was on exhibition in a travelling show as 
the "Elephant man." In his case the head attained 
massive proportions. 

Etiology. — The disease occurs in both sexes and in all 
ages, but is most common in men of middle life and in 
the dark-skinned races. Moncorvo 1 reports a case in an 
infant four months old, and speaks of a case in one fifteen 
days old. He believes that it may develop in utero. 
Floras 2 reports a case beginning at birth and remaining 
stationary for fifteen years, when it assumed the typical 
course of the disease. It is particularly prevalent in damp, 
malarious parts of the seacoast, and the mosquito is 
supposed to be the carrier of the infection. It is not 
supposed to be hereditary, though in countries in which 
it is endemic several members of the same family may 
be affected by it. Leprosy and elephantiasis have been 
accidentally associated. Exposure to cold, phlegmasia 
dolens, cellulitis, ulcers, lupus, repeated attacks of eczema 
or erysipelas, posture, as the hanging down of a limb 
on account of rheumatism, pressure upon veins or lym- 
phatics by tumors, may give rise to the disease. In 
fact, any disease of the skin that is attended by repeated 
inflammatory outbreaks favors the occurrence of ele- 
phantiasis. The filaria sanguinis is said to be the cause 

1 Rev. mens, des 'Mai. de l'Enfance, 1886, iv, 101. 

2 Arch. f. klin. Chirurgie, 1888, xxxvii, 598. 



268 DISEASES OF THE SKIN 

of the endemic form of the disease. It is not, found in 
every case, and is rarely encountered in sporadic cases. 

Pathology. — Anything that will occlude the lym- 
phatic or venous channels may cause the disease. In 
endemic cases it is the adult filaria that do this. In 
sporadic cases the several etiological factors play the 
same part. However caused, the result is an enormous 
hypertrophy of the subcutaneous tissue from increase of 
fibrous tissue in various stages of development. The 
corium is also increased in thickness, and there is pro- 
liferation of the epidermis, enlargement of bloodvessels, 
lymphatics, and nerves. In advanced cases the muscles 
undergo fibro-fatty changes, and the bones become 
enlarged (Crocker). 

Diagnosis. — The recognition of elephantiasis is easy, 
as its symptoms are pronounced. In some cases of 
syphilis, however, an elephantiasic thickening of the foot 
or feet takes place that may be thought to be elephan- 
tiasis. In it, however, there is an absence of the history 
of repeated inflammatory attacks, the outline of the 
thickening is rather well defined, and old cicatrices or 
ulcers characteristic of syphilis will commonly be found. 
The condition is one of gummatous infiltration with 
chronic edema, consequent upon obstruction of the 
lymphatics. 

Treatment. — The best thing for a patient with 
endemic elephantiasis to do is to go to a more health- 
ful climate. The treatment of the patient during the 
exacerbations is purely symptomatic, with rest in bed, 
fomentations, quinin, iron, and the like. Various measures 
for the cure of the disease have been proposed, but none 
is perfectly satisfactory. Of course, the scrotal tumor may 
be cut off. The leg has been amputated at the hip, a 
dangerous operation. Unfortunately, the other leg has 
become diseased soon after the one has been cut off. 
Ligation of the femoral artery has been performed, but 
the result has not been satisfactory. Compression by 
means of a rubber bandage, or the ordinary roller band- 



1$ — Potass, iodid., 


gr. xl 




2 


Potass, chlor., 


3j . 




4 


Sol. hydrarg. perchlor., 


5ss 




16 


Inf. chiretta, 


ad S viij 


ad 


250 


Sig. — gss t. i. d. 









EMPHYSEMA 269 

age, will afford relief. When it is left off for a time 
enlargement will again take place. It, of course, cannot 
be used while inflammation is present. Bentley 1 has 
reported the cure of a case by the inunction of a J dram 
(2) of mercurial ointment twice daily, and the application 
of a firm bandage for fourteen days. After that the 
inunctions were made once a day. Internally he gave 
iodide of potash alone, or in this formula: 



M. 



A. Castellani 2 advises the removal of long elliptical 
strips of skin, and the hypodermic injection of fibro- 
lysin 2 c.c. (32 minims) every day or every other day 
for a month. After a week's pause it is to be given again 
for thirty or forty injections. A third course is to be 
given after a week's rest. An india-rubber bandage is 
to be worn throughout. 

Galvanism has produced alleviation, if not cure, in 
some cases. Pusey quotes a case cured by z-rays by 
Mascat. 3 Hardaway has seen great amelioration in one 
case by the use of Squire's glycerole of the subacetate of 
lead. Massage is beneficial. Stretching or excision of 
a part of the sciatic nerve is spoken of by J. Nevins 
Hyde as having been followed by amelioration of the 
condition. 

Prognosis. — Unless the patient is exhausted by the 
loss of lymph, the disease may last indefinitely without 
deterioration of the health. Death may result from 
pyemia or thrombosis. The patient often dies from some 
intercurrent affection. 

Elephantiasis Grecorum. — See Leprosy. 

Emphysema of the skin is a rare accident. It usually 
affects the upper chest and neck, and is due to a rupture 

1 Lancet, 1878, i, 785. 2 Jour. Cutan. Dis., 1908, xxvi, 225. 
3 Lancet, 1898, i, 544. 



270 DISEASES OF THE SKIN 

of the pulmonary alveoli on account of vomiting or 
paroxysmal coughing, and the air making its way under 
the skin. The affected part looks swollen, feels cushiony, 
and gives a delicate crackling sound on palpation. There 
will be a history of the sudden occurrence of the swell- 
ing after coughing or vomiting, and probably more or 
less dyspnea will be experienced. The air slowly escapes 
and the parts return to their normal condition. 

Fig. 29 



t. 





* 



Endothelioma. (Spiegler.) 



Endothelioma.— Under this title E. Spiegler 1 and others 
have reported several cases of tumors that occurred in 
adult life, upon the scalp especially, but also on other 



Arch. f. Dermat. u. Syph., 1S99, 1, 163. 



EPIDERMOLYSIS BULLOSA 271 

regions. They were present in great numbers and tended 
constantly to increase in number and in size. They 
varied in size from a pea to an orange. They projected 
high above the level of the skin, and were round or flat- 
tened. They were firm • and elastic, and were either 
covered with smooth adherent skin or superficially 
excoriated or ulcerated. The apposed surfaces of neigh- 
boring tumors were often deprived of epidermis, bled 
slightly, and secreted a seropurulent, badly smelling 
fluid, which dried into crusts between the tumors. In 
one of the cases the disease had lasted forty years, and 
there was a history of the first tumor having appeared 
after the healing of a cut of the scalp. Endotheliomas 
may occur elsewhere than on the scalp. Gottheil 1 re- 
ported one on the foot. It was a black tumor, irregular 
in shape, rounded, sharply defined, slightly elevated, 
and smooth, excepting for two or three small orifices 
from which blood serum exuded. It was cut out and 
returned. The diagnosis of these tumors cannot be 
made with certainty without the aid of the microscope. 
These tumors originate in the endothelium lining the 
lymphatics or bloodvessels. 

Ephelides.— See Lentigo. 

Epidemic Skin Disease of Savill. — See Dermatitis 
epidemica. 

Epidermolysis Bullosa. — Synonyms: Acantholysis bul- 
losa (Goldscheider and Joseph); Dermatitis bullosa 
(Valentine) . 

This is a rare disease, or rather peculiarity of the 
skin, in which bullae arise upon the slightest pressure. 
The disease usually first appears in infancy, but may 
do so later in life, and occurs especially upon the 
hands and feet, but may occure anywhere on the body, 
cases having been reported as occurring in the mouth. 
The tendency to the formation of bulla? lessens toward' 
middle life. The lesions begin either as red spots, which 

1 Jour. Amer. Med. Assoc, 1907, xlvii, 93. 



272 DISEASES OF THE SKIN 

are itchy, or without precedent redness or other subjective 
symptoms. A bulla begins to form shortly after the 
exciting pressure, such as from the shoe in walking, or 
even friction from a suspender, has been received, and 
keeps on enlarging for two or three days. It then grad- 
ually decreases, dries into a crust, which falls, leaving 
healthy skin. If the bulla is broken, it discharges a 
yellow, slightly sticky fluid, and leaves a suppurating 
base. It may be hemorrhagic. The disease is heredi- 
tary in certain families, but it may occur independently 
of this. It is most pronounced in summer time. In 
most cases there is hyper idrosis. 

Pathology. — Elliot, 1 from his microscopical study of 
the disease, believed it to be "due in a predisposed 
individual to an excessive response on the part of the 
bloodvessels to an external irritation, and the consequent 
pouring out of an enormous amount of serous exudation." 
He regarded it as an "inflammatory process, originating 
in the cutis itself, and manifesting itself by the formation 
of bullae after slight or severe traumatisms." J. Bukov- 
sky 2 found no change in the unaffected skin, and believed 
that it is dependent upon some physical defect, such as 
an inequality of contractility of the skin. Engman and 
Mook 3 in one case found an absence of elastic tissue in 
the papular and subpapular parts of the skin, and sparsely 
distributed and deformed in the deeper parts. On this 
account the skin vessels lose their tonicity, and slight 
trauma is followed by an excessive flow of serum into 
the tissues. 

Treatment. — No treatment is of avail. 

Epithelioma. — Synonyms: (Ft.) Epitheliome cancroiide; 
(Ger.) Epithelialkrebs ; Cancroid, Skin cancer, Epithelial 
cancer, Noli me tangere, Rodent ulcer. 

Epithelioma is a chronic, progressive, malignant new 

1 Jour. Cutan. and Gen.-Urin. Dis., 1895, xiii, 10. 

2 Archiv. Dermat. u. Syph., 1903, lxvii, 163. 

3 Jour. Cutan. Dis., 1906, xxiv, 55. 



EPITHELIOMA 273 

growth in the skin or mucous membrane, which is char- 
acterized by the formation of ulcers with raised, hard, 
waxy edges, and by a strong tendency to return after 
apparent removal by knife or caustic. 

Symptoms. — There are two varieties of epithelioma 
of the skin. The first is the least malignant, the basal 
cell variety or the superficial, usually not involving the 
lymphatic glands, nor producing metastases. The 
rodent ulcer is the type of this variety. The second 
variety is the spinocellular variety, which most often 
occurs at the mucocutaneous junctures, begins commonly 
as a node, which soon breaks down and ulcerates, involves 
the lymphatic glands, is prone to metastasize, and is 
malignant. Epithelioma always begins in a most innocent 
manner, and may be present for months or years before 
the patient dreams that he has a serious disease. It 
may occur upon the skin alone, or upon the mucous 
membrane alone, or upon both the skin and mucous 
membrane at their line of juncture. Epitheliomas 
occurring upon the tongue, larynx, or uterus do not 
concern us here, as they belong to the domain of surgery. 

The starting-point of the disease may be a crack or an 
abraded scaly spot, as on the lip; a small, flat, scaly, 
sebaceous patch; a white, pearly looking, hard nodule; 
a senile or other wart or papilloma; a pigmentary mole; 
a cicatrix; an adenoma; a chronic or lupous ulcer; a 
psoriatic patch, or some other new growth in the skin. 
Some of these lesions may have been present for many 
years, as, for instance, a mole. Some appear but a short 
time before they frankly declare their nature, such as 
the waxy nodule. However it may begin, it will be 
noted that the previously existing lesion more or less 
rapidly becomes more dense, and after a varying time 
ulceration occurs, the disease spreads at its edges, and 
the ulceration grows deeper and deeper, in the infiltrating 
or spino-cellular form, eating its way through skin, 
muscles, and bone, or creeping over the surface in the 
most superficial or basal form. The lymphatic glands 
18 



274 DISEASES OF THE SKIN 

may be involved early in the course of the disease in the 
deep forms, or not for many years in the superficial 
forms and then commonly the results of secondary 
infection of the ulceration. Eventually they may be- 
come swollen, hard, break down, and ulcerate, assuming 
the appearance of an epitheliomatous ulcer. A typical 
epitheliomatous ulcer is irregular in shape, with raised, 
hard, waxy-looking, rounded, or everted edges, over 
which, quite commonly, course dilated bloodvessels; the 
floor is uneven, bleeds easily when touched and is cov- 
ered by a brownish crust or a sanious, purulent secretion. 

Fig. 30 



Epithelioma. (From Prof. G. H. Fox's service at the 
Vanderbilt Clinic.) 

Epitheliomas are usually single lesions, but they may 
be multiple. Sometimes a single epithelioma attains vast 
dimensions, involving the whole of one side of the face, 
scalp, and neck in one huge excavated ulcer. Sometimes 
before the characteristic ulceration develops the new 
growth may take the form of a single enlarged papilla 
or a group of them. In some cases it may have a cauli- 
flower-like appearance, spreading out from a more or 
less narrow base. Fissures are apt to form between the 
papillae, and then there is usually an offensive discharge. 
This is called the papillary form. 

Subjective symptoms are absent in many cases at first, 
but in the deep, infiltrating form pain of a lancinating 
character is present, This often is so severe that the 



EPITHELIOMA 



275 



sufferer is robbed of his sleep. In the small and more 
superficial cancers there commonly is no pain, and the 
patient experiences only the discomfort incident to the 
ulceration. If the ulcer extends and goes deep so as to 
implicate nerves, in nearly all cases lancinating pain is a 
symptom of the disease. 

Fig. 31 




Epithelioma of the nose. Exuberant growth due to stimulatioi 
a tar ointment given by a quack. 1 



The course of the disease is always chronic. Different 
cases show different stages of malignancy. Some will 
prove fatal in four years or less; some will last indefi- 
nitely. There is no tendency to recovery, though at 
times a partial attempt at healing will be made. Super- 
ficial epitheliomas may creep over the skin, healing up in 
the older parts while spreading outward. While all 
epitheliomas show a strong tendency to return after 

1 Courtesy of Dr. H. Fox. 



276 DISEASES OF THE SKIN 

operation and in the scar left by it, in some cases this 
tendency is much more marked than in others. 

While epithelioma may occur upon any part of the 
body, it is most frequently located upon the lower lip, 
where it occurs, according to Paget, in 50 per cent, of 
the cases and is of the spinocellular type. It is very 
common for it to begin as a crack in the vermilion 
border, which does not heal but begins to infiltrate later- 
ally and form a dense well-defined mass with a strong 
tendency to ulcerate. The neighboring lymphatic glands 
are involved early in this form. The next most common 
location is the face. A favorite location upon the face 
is upon the side of the nose and near the inner canthus 
of the eye. Here it is very apt to pass over on to the eyelid 
and destroy it. Not infrequently it begins upon the 
eyelid itself. The external genital organs of both sexes, 
and the anal region more rarely, are other common sites. 
The upper lip is very rarely affected. 

It is customary to describe a number of forms of 
epithelioma, but it seems much better, especially for 
a student, not to encumber his mind with too many 
names. The superficial, deep-seated or infiltrated, and 
the papillary forms have already been mentioned. The 
chimney-sweep's cancer is an epithelioma of the scrotum 
met with in paraffin- workers and chimney-sweeps. The 
rodent ulcer used to be described as a special form of 
disease, and still is so by English surgeons. Clinically, 
it is supposed to be characterized by occurring on the 
skin of the upper half of the face, by running a slow and 
painless course, by not involving the lymphatics, and 
by lateral rather than perpendicular extension. M. B. 
Hartzell 1 has described a "morphea-like" epithelioma, of 
a yellowish-white or pink color, oval shape, and typical 
wavy border. 

Etiology. — The cause of epithelioma is undetermined. 
We know that repeated irritation of a part is often 

1 Jour. Amer. Med. Assoc, 1909, liii, 262. 



EPITHELIOMA 277 

followed by its advent. Smoking short clay pipes is 
not uncommonly followed by epithelioma of the lip; 
a ragged tooth accounts for many an epithelioma of the 
tongue; the wearing of spectacles or eye-glasses has in 
some cases apparently caused the new growth upon the 
nose; constant picking or inadequate attempts at the 
removal of warts and scaly spots would seem to account 
for some epitheliomas of the face; and the scratching to 
relieve pruritus of the anus may play the same part in 
producing the disease about the anus. This constant 
irritation would explain the appearance of epithelioma 
in paraffin-workers and chimney-sweeps, in chronic 
ulcers, psoriasis, old cicatrices, and the like. J. N. 
Hyde 1 sees in the action of the sun's rays a possible 
cause, and draws attention to the fact that the face and 
hands are the common sites of the disease. It is to the 
blue and ultraviolet rays that this action is due. Further, 
it is more common in men than in women; in farmers 
than those living in cities; and rare in negroes who are 
protected by an abundant pigment. Xeroderma pig- 
mentosum, caused by the action of sunlight, has epithe- 
lioma as a common sequence. A congenital or acquired 
phimosis and the repeated inflammation due to decom- 
posing smegma are forerunners of the disease upon the 
penis. Age is the most pronounced predisposing cause. 
The disease is rare under thirty years of age, and increases 
in frequency beyond that period. One case has been 
reported by Kaposi in the tenth year of life. Heredity 
has some influence, though D. Lewis has found that it 
is not so well marked as it is frequently assumed to be. 
Males are more often affected than females. It seems 
to have a predilection for all neoplastic growths. The 
theory that it is due to a specific parasite, and therefore 
contagious, thus far has not been demonstrated. 

Pathology. — Epitheliomas take their origin from the 
cells of the skin appendages, hair follicles, sweat or 

1 Amer. Jour. Med. Sci., 1906. 



278 DISEASES OF THE SKIN 

sebaceous glands, from misplaced enibryological epithe- 
lium, or, by far most frequently, from the rete Malpighii. 
Histologically, the tumors are most conveniently con- 
sidered in two classes which are morphologically quite 
distinct. The difference between the two depends not 
so much upon the point of origin of the growth, as upon 
the tendency of the tumor cells, in the one instance to 
continue a process of specialization, similar to the normal 
development of the cells from the stratum mucosum to 
the stratum corneum, or, in the other, to revert to a 
more primitive and embryological type. Tumors of the 
latter class are known as basal-celled epitheliomas. 

In both forms the essence of the process is a prolifera- 
tion of epithelial cells of varying size and shape. The 
resulting cell masses penetrate the corium and often fuse 
with the formation of alveolar structures, the trabec- 
ular of which, on section, show dendritic branching. 
Proliferating epithelial nipples project into connective 
tissue, which, as far as amount and density are con- 
cerned, varies greatly, but is always very cellular, rich 
especially in plasma and giant cells and mononuclear 
leukocytes. 

In the first class the epithelial cells have in a measure 
the life history of normal epithelium, but as they are no 
longer growing on a free surface, but in enclosed spaces, 
they become packed in masses, the older cells being 
forced toward the centres so that at length there are 
formed concentrically arranged cell masses, which, when 
cut across present the dense white, lamellated, rounded 
structures which have been called epithelial pearls. Such 
pearls are rarely found in other conditions, although they 
may be present whenever any lesion involves the growth 
of epithelium into a limited space. In doubtful cases 
their occurrence with other marks of corniflcation and 
the presence of intercellular bridges may be of great 
diagnostic importance. There is variation in the degree 
and depth to which the corium is invaded. In rodent 
ulcers the tendency of the growth is to remain near the 



EPITHELIOMA 279 

surface, proliferation and metamorphosis are slow, and 
necrosis and cicatrization extend pari passu with the 
lateral growth of the tumor. In larger tumors ulcera- 
tion takes place at the centre, while the edges become 
elevated by the papillary hyperplasia, extension of the 
tumor beneath the skin, and the inflammatory infiltra- 
tion. Before ulceration the tumor may project above the 
skin forming a wart-like or papillomatous growth. 

In the second group the tumor cells resemble those of 
the rete mucosum, or of certain glands, but in their retro- 
grade metamorphosis take on the appearance of connec- 
tive-tissue cells, so that at times the tumor merges into 
the stroma with no sharp line of demarcation. The 
proliferating cells may form solid masses of various 
shapes, and sometimes gland-like or cystic structures. 
Different forms of degeneration of the stroma contribute 
along with the metaplasia and appearance of embryonal 
characteristics, to the formation of a very complex 
structure. In this class are to be included many tumors 
which have been described as endothelioma, cylindroma, 
plexiform sarcoma, and myosarcoma. 

Diagnosis. — The disease must be differentiated from 
lupus, syphilis, sarcoma, papilloma, and seborrheal 
warts. From lupus it differs in an entire absence of 
brownish lupus tubercles; in beginning late in life, as a 
rule, while lupus begins in early life; by its compara- 
tively more rapid course; its lancinating pain; the in- 
volvement of the lymphatic glands; the deep ulceration; 
the waxy, raised, hard margin; and the development of 
the cancerous cachexia. From syphilis it differs in hav- 
ing a single and not a multiple lesion; in its slower course; 
in its showing no tendency to recovery; in its not respond- 
ing to internal treatment; in its painfulness; and in its 
waxy, raised, hard margin. An initial lesion of syphilis 
on the lip has not infrequently been taken for an epithe- 
lioma. In it we have more rapid growth, more induration, 
an early enlargement of the neighboring lymphatic 
glands of peculiar hardness, and the appearance of 



280 DISEASES OF THE SKIN 

secondary eruptions on the body, all of which are wanting 
in an epithelioma. Sarcoma usually occurs earlier in 
life, tends to more rapid development with metastases 
in neighboring or distant parts, and either does not 
ulcerate or ulcerates in a very different way than does 
epithelioma. From 'papilloma and seborrheal warts there 
are no positive diagnostic marks of distinction. Either 
of the two diseases appearing late in life or showing 
symptoms of activity at that time should arouse our 
suspicions. 

Treatment. — Complete and radical destruction of the 
disease is the only thing to be done in the treatment 
of epithelioma. As a prophylactic measure, it is well to 
destroy all suspicious warts appearing after middle life, 
and to apply appropriate treatment to seborrheal patches 
occurring at the same period. Superficial caustics should 
never be used to an epithelioma, as they only encourage 
its growth. The radical treatment will differ with the 
point of view, all surgeons inclining to the knife, while 
dermatologists advocate the curette or powerfully destruc- 
tive caustics. If the knife is used, it must cut out a 
wide margin beyond the growth. Extirpation is espe- 
cially applicable, and the most appropriate treatment for 
epithelioma of the lip, eyelids, and penis. In the latter 
the organ must be amputated above the ulcer, if that has 
attained any size, and the inguinal glands likewise taken 
out. In all cases in which the lymphatic glands have 
become involved they should be taken out. Therefore 
when the lymphatic glands are involved only excision 
is to be thought of. 

Curettage and the thorough application of powerful 
caustics effect a speedy and rapid cure of all forms of 
the disease. We have found the method advocated by 
S. Sherwell 1 most excellent. In small lesions it is unneces- 
sary to use general anesthesia, local anesthesia by cocain 
or the like being sufficient. In large growths general 

1 Jour. Cutan. Dis., 1910, xxviii, 487. 



EPITHELIOMA 281 

anesthesia is necessary. The growth must be energetically 
scraped away with a curette until all the dead tissue 
is removed. Then a small curette is to be used, seeking 
out all small pockets. The bleeding is checked by pres- 
sure, or by applying a solution of two-thirds of a 10 per 
cent, solution of cocain and one-third of adrenalin under 
pressure or by touching with a Paquelin cautery at cherry 
heat. Then a 60 per cent, solution of acid nitrate of 
mercury is to be applied with a cotton swab two or 
three times and allowed to remain on for five to twenty 
minutes, when it is neutralized with a saturated solution 
of bicarbonate of soda, and the hole filled up with 
powdered bicarbonate of soda. The crust is allowed to 
separate of itself, which it will do in two or three weeks. 
For a few days there may be considerable inflammatory 
reaction, that need give no anxiety. 

Fig. 32 





The dermal curette. 

Epithelioma may also be destroyed by caustics. 
Arsenic holds the first place among these, Marsden's 
paste, composed of 1 or 2 parts of arsenous acid and 
1 part of gum acacia, by weight, rubbed together and 
mixed with a 20 to 40 per cent, aqueous solution of 
cocain into a paste of the consistency of butter just 
before using, is perhaps the most often used. It is dread- 
fully painful and often causes great edema. If orthoform 
is substituted for \ to f of the gum acacia, the paste is 
hardly at all painful. Before applying an arsenical 
paste, if ulceration has not taken place, the epithelium 
should be curetted so as to leave a raw surface. The 



282 DISEASES OF THE SKIN 

paste should be applied to the affected part spread on a 
piece of linen large enough to overlap the edge of the 
tumor by half an inch, and left on for twelve to twenty- 
four hours, according to the patient's endurance and the 
effect produced. The patient should be seen frequently, 
and the paste removed as soon as a greenish or blackish 
eschar is formed. Carbolated vaselin is to be applied 
after the paste, and kept on continuously until the 
slough separates, and then simple ointment used. The 
slough may not fall for weeks, and when it does a 
clean surface is exposed that soon completely heals. 
It is to be noted that the use of a strong arsenical paste 
is much safer than a weak application, as it produces 
so much inflammation and destruction of tissue that the 
arsenic is not absorbed. Arsenic is better than some other 
caustics, as it attacks by preference diseased cells and 
leaves the sound skin almost unharmed. If the growth 
has not been destroyed, the process may be repeated. 
D. Lewis 1 has had good results from using Bougard's 
paste, as follows: 



i — Wheat flour, 








Starch, . 


aa 


60 




Arsenic, 




1 




Cinnabar, 








Sal. ammoniac, 


aa 


5 




Corrosive sublimate, 






50 


Solution of chloride of zinc at 52°, 




245 


M 



The first six ingredients are separately ground to a fine 
powder and mixed in a mortar. Then the solution of 
zinc is slowly added while the mass is stirred. It is to be 
kept covered in an earthen jar. A portion is to be applied 
accurately to the part and kept on for thirty hours, and 
followed by a poultice. Cocain, 20 per cent., may be 
added to decrease the pain. Another method of using 
arsenic is known as Cerny's. He uses: 

1$ — Acid, arsenios. pulv., 1 

Alcohol, ethyl, absolut., 
Aqua? destillat., aa p. e. ad 150 

1 Jour. Cutan. and Gen.-Urin. Dis., 1890, viii, 70. 



EPITHELIOMA 283 

The solution is to be shaken up and painted over the 
denuded surface of the epithelium, and a new coat laid 
on when the first is dry. It is used daily unless oedema 
is caused, when a pause is made until this subsides. After 
a time an eschar forms and falls. The solution is then 
applied again to the surface, and if only a yellowish crust 
forms that can be removed without bleeding, a cure has 
been effected. If a dark adherent crust forms, repeat as 
before. Healing at last is effected under 10 per cent, 
boric acid in vaselin. 

Lactic acid is another powerful caustic, to be applied 
by mixing it with an equal part of finely powdered silica 
and spreading it upon gum paper. It is kept on for 
twelve hours, and renewed twenty-four hours afterward. 
Hardaway prefers to apply the syrupy acid by means of 
absorbent cotton for ten or fifteen minutes, and then wash 
off the excess of acid with water. This is done daily. 
Caustic potash and chloride of zinc in crayon are recom- 
mended by A. R. Robinson for epithelioma of the lip and 
small epitheliomas about the eyelids. The first is a con- 
venient agent in the form of potassa fusa. It is well to 
curette away the surface, and then to hold the potash 
stick against the wound for a few moments until the tis- 
sues liquefy. The application of dilute acetic acid will 
check the action of the potash. A raised scar sometimes 
follows its use. It will flatten in time. 

The thermo- and galvanocautery and chloride of zinc 
may be used. 

X-rays in massive doses, as employed by MacKee (p. 
■471), give brilliant results. He advises me that the 
ordinary basal cell epithelioma will yield, as a rule, 
to one or two treatments, consisting in quantity of 
from 6 to 8 Holzknecht units, and in quality of Benoist 
Xos. 8 to 10. If deep seated or of the squamous cell 
variety, the same quality should be filtered through 3 
mm. of aluminum, and as much as 12 to 18 Holzknecht 
units given at one time. As no pain or inconvenience 
is caused by this method, and the results are speedily 



284 DISEASES OF THE SKIN 

obtained, it is to be preferred in the hands of an expert. 
Repeated exposures to arrays will also cure. A medium 
hard tube should be used, exposures should be made 
every other day, the patient should be from four to 
ten inches distant from the target, and the duration 
of each sitting should be from three to ten minutes. 
The surrounding parts should be protected by sheet 
lead in which a hole is cut a little larger than the size 
of the cancer. The hard edges should be removed by 
curettage. It may take six to ten weeks to effect a 
cure. This is often effected without the production of 
erythema. Treatment should be suspended when reac- 
tion appears. It should not be resumed under three 
weeks. Radium will cure superficial epitheliomas. 

Prognosis. — The prognosis of epithelioma as to life 
is good in cases in which only the skin is involved. 
While, as already said, there are some cases that are 
rapidly fatal, many do not seem to have any effect on 
the patient's health for years. The prognosis as to cure 
is always doubtful. Some cases, whether excised, or 
destroyed by other means, will return after a time. 
If they do return, they must be destroyed again. 

Epithelioma, Multiple Benign Cystic. — Under this title 
Fordyce 1 places those cases formerly described under the 
names of hydradenomes eruptifs, syringo-cystadenome, 
epithelioma adenoides cysticum, and other titles. It is 
characterized by the eruption of small, pale-yellow, 
pearly, pinkish, brownish, or reddish-brown tumors 
from pinhead- to pea-sized, that are located on the 
face, chest, back, and upper extremities. They are firm 
to the touch, and painless. Some of the tumors are 
tense, shiny, freely movable, sometimes with a central 
depression. Some are translucent, like vesicles; some 
look more like milia. They slowly increase in number, 
the individual tumors enlarging to the size of a pea 
and then remaining stationary. The disease has no 

1 Jour. Cutan. and Gen.-Urin. Dis., 1892, x, 459. 



EQUINIA 285 

effect on the general health. In most cases it is 
hereditary, and begins in early life. The diagnosis from 
adenoma sebaceum is very difficult, and often cannot 
be made without the aid of the microscope. Molluscum 
contagiosum often occurs in childhood and always has 
a central punctum. Hydrocystoma contains fluid. 

Microscopic examination shows the tumor to be made 
up of irregular masses and tracts of epithelial cells, and 
"cell nests." Colloid degeneration of individual cells 
is also seen in the cell masses. There are also a down 
growth and proliferation of the epidermis and external 
root sheath of the hair follicle. It is supposed that the 
growths are due to misplaced epithelial cells of indifferent 
nature (Fordyce). 

Their treatment is by curetting or electrolysis. 

Equinia.- — Synonyms: Glanders; Farcy; Malleus; (Fr.) 
Morve; (Gr.) Rotz. 

A contagious, specific disease, with general and local 
symptoms, derived from the horse, ass, or mule. 

This is a rare disease in the human race, and runs an 
acute, subacute, or chronic course. It is derived by inocu- 
lation with the bacillus mallei, and its symptoms show 
themselves in from three days to six weeks afterward. Its 
constitutional symptoms are fever, prostration, constipa- 
tion, and rheumatic pains, with the subsequent develop- 
ment of a typhoid condition in which the patient dies. 
The objective symptoms are a profuse purulent or sanious 
nasal discharge; chancroidal ulceration at the site of 
entrance of the poison; phlegmonous inflammation of the 
affected part; adenitis; and a cutaneous efflorescence. 
The latter is a disseminated eruption of red macules, which 
develop into yellow papules, upon which variola-like 
pustules and bullae may form. These may coalesce into 
superficial ulcerations and gangrenous patches. The skin 
is swollen and red, and often crusted with the discharge 
from the pustules. Infiltration of the subcutaneous 
tissues may occur and deep sloughs may form. There may 



286 DISEASES OF THE SKIN 

be a general adenitis, and the glands may break down 
and form ulcerating cavities. The whole skin may be 
involved in these destructive processes. It may run an 
acute or chronic course. 

Treatment is usually unavailing in acute cases, and is 
on general principles. In chronic cases recently cures 
have been effected by the hypodermic use of mallein, 
a serum derived from cultures of the bacillus. The 
initial dose is 1 mg., increasing in the course of a week or 
so to from 30 mg. to 1 gm. The prognosis is bad. The 
more acute the symptoms the worse the outlook. 

Erysipelas. — Synonyms: (Fr.) La rose, Feu sacre; (Ger.) 
Rothlauf, Rose, Hautrose, Wundrose; (It.) Risipola; St. 
Anthony's fire, Wildfire, Rose. 

An inflammatory disease of the skin and the adjacent 
mucous membranes, attended always with redness and 
swelling, and often with vesicles, bullae, pustules, diffuse 
suppuration, and gangrene; and characterized by a ten- 
dency to spread at the periphery and by fever (Foster). 

Symptoms. — Though the most modern pathology 
teaches that erysipelas always originates in or about a 
lesion of the skin or mucous membrane, and is therefore 
allied to if not indentical with the same disease as met with 
in surgical and lying-in wards, so-called surgical erysipelas 
will not be considered here. The outbreak of the disease, 
as met with apart from the surgical form, is usually pre- 
ceded, for a day or so, with malaise, and the attack is 
often ushered in with a chill, pyrexia, and vomiting. The 
fever is present throughout the whole course of the dis- 
ease, excepting in the most mild type, when it may soon 
subside. The thermometric range is from 101° to 105.5° 
F. The highest temperatures usually are at night. If 
there should be a sharp rise of temperature it indicates 
an exacerbation or invasion of new territory. It is remit- 
tent in type, irregular in course, and ends by lysis. Some- 
times the temperature is subnormal. There will be other 
signs of constitutional disturbance, such as a coated 



ERYSIPELAS 287 

tongue, a quickened pulse, either full, soft, and compres- 
sible, or, in bad cases, small and weak; headache, drowsi- 
ness, or, in bad cases, delirium; and sometimes albumin 
is found in the urine. 

The most frequent location of the disease, so far as we 
now are concerned, is the head and face, though it may 
occur anywhere on the body. The eruption begins usually 
as a single patch, which is at once rosy red, swollen, 
sharply defined, irregularly shaped, hot to the touch, and, 
at first, with a smooth, glazed surface. The redness may 
be pressed out with the finger, leaving a yellow stain, but 
promptly returns when the pressure is removed. The 
patch enlarges, creeping with more or less rapidity over 
the surface, always preserving its sharp, ofttimes indented 
border that is raised toward the sound skin; it becomes of 
a darker hue, sometimes livid; and very commonly, 
though not uniformly, vesicles or even blebs form on it. 
These latter may become purulent, and breaking, dis- 
charge their contents upon the surface, which dry into 
crusts. As the process extends the central portion 
becomes flattened and less red. Sometimes new patches 
may appear, and coalesce with the original patch. Some- 
times, while spreading peripherally, there may be a 
recrudescence in the older parts. The area of the disease 
may be limited or may include the whole body. Very 
often it seems to be checked by the line of the hair, 
whether of the beard or scalp. In only a small pro- 
portion of cases does it invade the hairy parts, involving 
one-half or the whole of the scalp and extending down 
upon the neck. Then the patient's appearance is indeed 
deplorable. His lips are swollen and livid, his eyelids 
are swollen so that the eyes cannot be opened, and his 
head seems enormously enlarged. Abscesses may form 
in the scalp. 

At times there may be a lighting up of the disease on a 
distant part of the body, as on the arm with erysipelas 
of the face. This is known as erysipelas migrans. The 
lymphatics and the lymphatic glands are involved. The 



288 DISEASES OF THE SKIN 

former often show themselves as red streaks. The glands 
may suppurate, and gangrene of the skin may declare 
itself. All grades of inflammation may be reached. Some- 
times the disease is but slight, sometimes very severe, 
the constitutional symptoms keeping pace with the 
severity of the local symptoms. The duration of the 
disease may be six or seven days, or two or three weeks. 
The patient is always more or less prostrated by it, though 
many of the cases we see are ambulant cases. Des- 
quamation follows on the subsidence of the disease. 

The subjective symptoms are burning, tingling, itch- 
ing, and tension. The parts are often tender, and may 
be spontaneously painful. 

The disease quite commonly begins about the nose, and 
may invade the mouth. Occasionally it spreads rapidly 
over the surface as an advancing, broad, rosy-red, raised 
line. Sometimes recurrent attacks occur at short inter- 
vals; generally the disease does not recur. When the 
scalp is invaded the hair commonly falls during con- 
valescence. Sometimes some lesion of the skin may be 
found as the starting-point of the inflammation, or per- 
haps some lesion of the mucous membrane of the nose, 
mouth, or ear. In the recurrent attacks the nose is quite 
commonly the peccant member. But in a very large 
proportion of cases no lesion at all will be discoverable. 
When the disease subsides the skin desquamates, and 
returns at last to the normal condition. 

Erysipelas occurring upon the trunk or extremities 
presents pretty much the same symptoms as when 
occurring upon the face. 

Etiology. — It is now generally accepted that the 
disease is infectious, and caused by a specific micro- 
organism that was described by Fehleisen, 1 which is a 
streptococcus. Stelwagon states that a special diplo- 
coccus was found in eight cases in the Philadelphia 
Hospital. The coccus gains access to the body through 

1 Deutsche Zeitschrift f. Chirurgie, 1882, xvi, 391. 



ERYSIPELAS 289 

some lesion of continuity of the skin or mucous mem- 
brane, however, minute that may be. It therefore some- 
times follows boils, tubercular ulcers, eczema, and other 
skin diseases. As in many of the bacterial diseases, so in 
this one, it is probable that the patient must be in the 
proper condition of health, or rather ill-health, for the 
lodgement of the cocci. One attack predisposes to another 
attack. In frequently recurring cases infection probably 
takes place through some lesion of the nose or naso- 
pharynx. It is more frequent in women than in men; in 
adults than in children; and in winter than in summer. 
Intemperance, Bright's disease, parturition, and a lowered 
state of nutrition predispose to it. While the contagious- 
ness of surgical erysipelas is well known, and commonly 
observed, it is rare to meet a case of facial erysipelas 
traceable directly to contagion. The possibility of the 
occurrence of the disease without infection by the micro- 
organism is still entertained by some. It has been 
thought to arise from taking cold or to begin in some 
circumscribed purulent deposit. 

There is nothing specific about the pathological anatomy 
of the disease. 

Diagnosis. — If the clinical features of the disease are 
kept in mind, the sharply defined, swollen, red patch 
advancing with more or less steadiness over the surface, 
the process being preceded by a chill and accompanied 
by marked constitutional disturbance, there is little 
danger of not recognizing it. It may, however, be mis- 
taken for dermatitis venenata, an acute erythematous 
eczema, an erythema, or so-called giant urticaria. In 
dermatitis venenata there is little or no constitutional 
disturbance, the patches are covered over thickly with 
large, well-preserved vesicles, and a history of exposure 
to some source of poisoning is usually easily obtainable. 
Moreover the disease is commonly upon the face and 
hands at the same time. In eczema the parts are not 
so swollen; the margin of the patch fades into the sur- 
rounding skin, the color is not so brilliant; the surface is 
19 



290 DISEASES OF THE SKIN 

rougher and more scaly; there is decided itching and a 
lack of constitutional disturbance of any magnitude. 
Erythema lacks the constitutional symptoms of erysipelas ; 
the redness fades completely away under pressure, without 
leaving a yellowish stain, and springs back promptly 
when the pressure is removed; it does not creep over the 
skin; and it is of short duration. In urticaria there will 
usually be well-marked wheals or a history of them; 
great itching; no tenderness; a short course; a history 
or evidence of digestive disorders, and an absence of 
marked constitutional disturbance. 

Treatment. — The great variety of remedies that have 
been vaunted for the cure of erysipelas evidences the 
fact that most cases recover of themselves. There are 
not a few competent observers who are skeptical of the 
real efficacy of any local treatment. As the disease tends 
to lower the vitality of the patient we should strive to 
support his strength by a most nutritious diet, and by 
alcoholic stimulants in adynamic cases. The internal 
medication will be symptomatic to a large extent, by 
means of aconite, quinin, antipyrin, phenacetin, and the 
like. The tincture of the chloride of iron, in 20 (1.33) to 
60 minim (4) doses every two or three hours, is regarded 
by many as a specific, and should be given in all but the 
slightest cases. Jaborandi by the mouth, or pilocarpin, 
J to i of a grain hypodermically, have their advocates, 
but must not be thought of in debilitated subjects. In 
severe cases injections of streptococcic vaccines are 
advisable. Johnson 1 advises giving 10,000,000. This 
may be repeated on the second day, then every second 
day, until one week after the temperature has become 
normal. S. Erdman 2 found vaccines to be of little use, 
as also Engman has. 

The local treatment is very important. If there is a 
wound present, it should, of course, be thoroughly 



1 Jour. Amer. Med. Assoc, 1909, lii, 747. 

2 Ibid., 1913, lxi. 2048. 



ERYSIPELAS 291 

disinfected on surgical principles. The lead-and-opium 
wash is an old remedy, and has proved useful in very 
many cases. It is composed of 

1$ — Liq. plumbi subacetat. dil., 5J-ii.J 4-12 

Tinct. opii, 5ij-iv 8-16 

Aquse, ad Oj ad 500 M. 

It may be used hot or cold, whichever is most agreeable 
to the patient. Dry heat will also relieve the discomfort 
of the patient. Resorcin in watery solution of 2 or 
3 per cent, strength seems at times to cut short the 
disease. White lead paint has done well in some hands. 
White 1 expects to cure his cases of ordinary facial ery- 
sipelas by keeping the part constantly covered with 
cloths saturated with the following: 

1$ — Ac. carbolici, 3J 4[ 

Alcohol., 
Aqua?, aa Oss aa 2501 M. 

It may be used every alternate hour. Carbolic acid may 
also be used in oil, 10 per cent, strength, and rubbed in 
every hour. Piffard recommends the external use of: 

J£ — Tinct. belladonna?, 1 part. 

Glycerini, 1 part. 

Aquae, 8 parts. M. 

Ichthyol, in 25 to 50 per cent, aqueous solution, is 
one of the best applications, the only objections to it 
being its disagreeable odor and dark-brown color. The 
parts should be constantly covered with it. Pure alcohol, 
frequently applied, is an agreeable and efficient remedy, 
as are cold compresses of a saturated solution of boric 
acid. 

The treatment by scarifications about the patch, the 
incisions being made diagonally, partly in the sound and 
partly in the diseased skin, and then covered with gauze 
wet with a solution of bichloride of mercury, 1 to 1000, 
is known as the Kraske-Riedel method, and should be 

1 Trans. Amer. Dermat. Assoc, 1890, p. 42. 



292 DISEASES OF THE SKIN 

always thought of in grave cases. Woelfler 1 recommends 
compression of the borderline by adhesive-plaster strips, 
the disease seldom spreading beyond the constricting 
band. This is especially applicable to erysipelas of the 
limbs. Painting with nitrate of silver all around the 
patch has also been done, with the idea of checking its 
spread. In many cases these procedures are useless. 

Prognosis. — Many cases of erysipelas recover of them- 
selves in a few days, while others may run a course of 
weeks. The prognosis may be said to be good in most 
cases; but even in those that begin as mild ones we should 
be on the watch for grave symptoms. When the scalp 
is affected or the disease spreads upon the trunk the 
prognosis is more grave than when the face alone is 
the seat of the disease. When the patient is the subject 
of chronic alcoholism, or Bright 's disease, or is in the 
puerperal state, or in either extreme of life, the prognosis 
is bad. 

Erysipeloid is a term employed by Rosenbach to desig- 
nate an erysipelas-like eruption unattended by constitu- 
tional symptoms. It is also called chronic erysipelas and 
erythema migrans. It orginates in a wound, is due to 
infection from some dead, putrefying animal substance, 
and chiefly affects cooks, butchers, fishmongers, and the 
like. Gilchrist 2 has seen many cases as the result of crab 
bites and believes it is caused by some special ferment. 
It occurs mostly on the fingers, and spreads from the 
point of inoculation as a dark-red, often livid, sometimes 
slightly swollen patch with a sharp border. As it travels 
over the surface the central portion undergoes involution, 
and thus circles or scalloped patches may be formed. 
It stops spontaneously after from one to six weeks' 
duration. There is marked itching or burning during 
the whole course of the disease. It is distinguished 
from true erysipelas by the mildness of its symptoms. 

1 Wien. klin. Wochenschr., 1889, Nos. 23 and 25. 

2 Jour. Cutan. Dis., 1904, xxii, 507. 



ERYTHEMA 



293 



A salicylic acid or other antiseptic ointment or a 50 
per cent, aqueous solution of ichthyol may be used in 
treatment. Gilchrist found the most effective treatment 
is to strap the edge of the swelling with a 25 to 50 per 
cent, salicylic acid plaster. 

Erythema. — Synonyms: Dermatitis erythematosa, Ery- 
sipelas suffusum; (Fr.) Erytheme, Darte erythemoide; 
(Ger.) Erythem, Hautrothe; Rose rash. 

Erythema may be passive or active. The former is 
familiar as lividity of the skin, and the latter as blushing. 

There are many forms of erythema as a disease, but 
they may all be classed under one of two main varieties, 
namely, Erythema hyperemicum and Erythema exuda- 
tivum. We shall follow Crocker's classification, as it is a 
practical one. It is a question whether erythema should 
be regarded as a disease or a symptom. 







1. Due to external 
causes 


f E. simplex. 

E. pernio. 
< E. intertrigo. 

E. leve. 




E. hyperemicum . 




[E. paratrimma. 


Erythema ' 


t E. exudativum 


2. Due to internal 
causes 

f E. multiforme. 
; E. seu Herpes iris. 
E. nodosum. 
.E. gangrenosum. 


f E. fugax. 

1 E. urticans. 

j E. roseola. 

IE. scarlatiniforme 



Erythema Hyperemicum. 

This form of erythema is characterized by simple red- 
ness without swelling, and usually is not followed by 
desquamation. This shows that it is due simply to a 
localized hyperemia without inflammation. It is always 
of short duration. The redness disappears under pressure, 
but springs back again as soon as the pressure is removed. 
It occurs either in circumscribed patches of large or small 
size, or diffused over large areas. Subjective symptoms 
are often hardlv noticeable. There mav be some burning 



294 DISEASES OF THE SKIN 

and tenderness, but there is never decided itching. The 
patient may rub his skin gently, but never scratches 
violently. In cases due to internal causes there may be 
slight constitutional symptoms with fever of mild grade, 
or some digestive disturbance; but these are not properly 
symptoms of the erythema, but rather of the underlying 
disease of which the eruption is but an accidental expres- 
sion. For instance, two people may eat the same thing. 
In both there may be digestive disturbances. But one 
will have an erythema and the other will escape. 

This form of erythema may arise from either external 
or internal causes. Cases arising from external causes 
are localized, while those due to internal causes are 
general. Both are angioneuroses, and predisposed to 
by an inborn susceptibility — that is, idiosyncrasy of the 
patient. 

In the first group we have Erythema simplex, under 
which are included E. traumaticum and E. caloricum, due 
to the rubbing of the clothing, the effect of heat or cold, 
as of the sun or wind, and of various vegetable or chemi- 
cal irritants. Many of these simple erythemas we have 
already described under the caption of Dermatitis, which 
see. They are the simplest reaction of the skin to an 
irritant. If the irritant is great enough or lasts long 
enough, a dermatitis is set up. They are usually local- 
ized, and for treatment require only the removal of the 
irritating cause, and the application of a simple dusting 
powder or ointment. The exciting cause continuing, we 
have inflammation added and a dermatitis produced. 

Erythema Pernio has been described under Dermatitis 
Congelationis, which see. 

Erythema Intertrigo, or simply intertrigo, is an ery- 
thema occurring between two folds of skin. It is most 
commonly seen in fat infants in the folds of the skin of 
the neck and joints. It is also encountered in adults who 
are corpulent, and is often a very annoying trouble in 
women, in whom it frequently occurs underneath the 
hanging breasts. It also occurs between the scrotum and 



ERYTHEMA 295 

inside of the thighs, under the prepuce, in the furrows 
alongside of the vulva, in the joints, and in all other skin 
creases. It is then caused by the friction in walking and 
favored by heat and moisture. It is therefore more 
common in warm weather. If not at once and properly 
attended to, the decomposition of the sweat and sebaceous 
matters will aggravate it; and the irritation being con- 
tinued, an eczema will develop. It is, in infants, very 
common about the inside of the thighs, where the wet 
napkins cause and aggravate it. It is very often accom- 
panied by a disagreeable, cheesy odor, and, contrary to 
what obtains in other erythemas, there is moisture upon 
the skin in some cases. 

Diagnosis. — The diagnosis from eczema is very often 
difficult. Indeed, eczema and erythema run into each 
other so imperceptibly at times that it is difficult to tell 
where the one leaves off and the other begins. But 
eczema itches more than erythema, it tends to spread 
further beyond the affected part, and its exudation is 
not only sticky, but also stains and stiffens linen. The 
location in the skin folds should suggest an intertrigo. 
Happily, the differentiation is a matter of no great 
importance, as the same treatment is applicable to both. 

In infantile syphilis we frequently have an eruption 
upon the buttocks and inside of the thighs that bears a 
decided resemblance to intertrigo. Here a correct diag- 
nosis is of great importance. In syphilis the redness 
commonly extends down the whole inside of the legs to 
the feet and soles, it is of a darker color, and there will be 
other symptoms of the disease, such as snuffles, large or 
small papules to the outside of the red patch, mucous 
patches, and the like. In infant asylums, where a great 
number of debilitated as well as syphilitic children are 
received, opportunities for the differentiation between 
syphilis and intertrigo frequently occur. 

Treatment. — The treatment of intertrigo is simple. 
The opposing surfaces of skin must be separated by 
pieces of gauze or muslin, the furrows must be kept 



296 DISEASES OF THE SKIN 

perfectly clean, by wiping the surface off with a saturated 
solution of boric acid, or, in adults where the skin is 
unbroken, with 90 per cent, alcohol, and dusting powders 
of starch, talc, lycopodium, and the like, must be freely 
used. To these powders oxide of zinc, boric acid, or 
other astringents may be added, the compound stearate 
of zinc being one of the best applications. Hardaway 
recommends : 

I$—-Thymol., gr. j |06 

Pulv. zinci oleat., gj 32 J M. 

As a rule, powders answer better than ointments, 
though Lassar's paste, as given under Eczema, may be 
used. Lotions, such as calamin lotion, and a saturated 
solution of boric acid, are preferable to ointments. The 
treatment of intertrigo in infants is to be managed in 
the same way as eczema. (See under Eczema Infantile.) 

Erythema Leve is an obsolete term, which was employed 
to indicate the redness seen on edematous limbs. 

Erythema Paratrimma belongs to the same category, 
only here it is the redness over bony prominences, as that 
preceding a bed-sore. 

We have now to consider the second group of erythema 
hyperemicum, those erythemas which are due to internal 
causes. Here might be placed all the exanthematous 
fevers, as well as the drug eruptions. But the first of 
these belongs to the domain of general medicine, and the 
last will be found under Dermatitis Medicamentosa. 

Erythema Fugax is, as its name indicates, a fugitive 
erythema — as it were, a prolonged blush. It occurs most 
often in children with some digestive disturbance, and its 
chosen location is the face. It lasts for a few moments 
or hours, and is seldom seen by the physician, although 
he will be told, not infrequently, by his patients that they 
are annoyed by a flushing of the face after eating, exposure 
to cold, or mental emotion. It is to be managed like 
Urticaria, which see. 



ERYTHEMA 297 

Erythema Urticans is simply the first stage of urticaria. 
The term should be dropped. 

Erythema Roseola, or simply roseola. "While children 
are more subject to this form of erythema than adults, it 
may occur in the latter. Most commonly it affects the 
whole body, but it may be localized. As it is due in 
most, if not all, cases to digestive disorders or other con- 
stitutional disturbance, it is usually ushered in with a rise 
of temperature, which may be pretty sharp, 103° or 104° 
F., furred tongue, restlessness, and the like. Soon the 
eruption appears, which may be a blotchy redness, or in 
faintly marked papules, or in rings or gyrate figures. 

The eruption lasts a few hours only, or, coming and 
going in different places, it may be prolonged for a few 
days. Besides digestive disorders, gout, changes of 
temperature, and the seasons of spring and autumn 
have been assigned as causes. 

Diagnosis. — In itself it is a matter of little moment, 
but as it resembles scarlet fever, rotheln, and measles, its 
diagnosis is important. It differs from scarlatina in not 
having such severe constitutional symptoms; in an 
absence of the strawberry tongue, swollen, reddened 
fauces, and enlarged glands; in the rash coming out all 
over the body without following any regular course of 
development from the neck downward; in the eruption 
being blotchy or papular, and not a diffused redness. 
After watching the case for a day the diagnosis will be 
made evident by the clearing away of the disease wholly 
or partially. It differs from measles in an entire absence 
of catarrhal symptoms, and in its eruption not being 
crescentic, as well as in the irregularity of its course, 
the mildness of its symptoms, and the brightness of its 
color. It bears most resemblance to rotheln, and probably 
the two are often confounded. If there is a clear history 
of contagion, or more than one member of the family 
affected at the same time, the diagnosis of rotheln is 
at once established. Rotheln is more pronounced on the 
extremities, and the lesions are of a more stable character. 



298 DISEASES OF THE SKIN 

In case of doubt as to the diagnosis of roseola the patient 
should be regarded as having a contagious disease, 
isolated, and carefully watched. 

Treatment. — Little need be done for the patient but 
to give a laxative, and to relieve symptoms. 

Erythema Neonatorum makes its appearance in the 
first few days of life, and is thought to be due to the 
influence of external and unusual irritants acting upon 
the tender skin of a newborn child. "The eruption 
consists of very minute red papules, seated upon a 
hyperemic base, which can be made to lose their color 
upon pressure. The lesions are most pronounced upon 
the back and breast, and fade away in a few days with 
slight desquamation of the most congested spots. The 
mucous membranes are unaffected, and there is no 
evidence of systemic reaction." (Hardaway.) 

Erythema Scarlatiniforme.- — A scarlatina-like erythema 
follows the ingestion of a number of drugs, and has been 
frequently mentioned in the section on Dermatitis Medica- 
mentosa. The French authors describe a scarlatiniform 
erythema under the name of erythemes scarlatiniform 
recidivantes, which, according to Besnier, 1 who has pub- 
lished an excellent study of the affection, was first 
described by Fereol in 1876, at the Societe medicale des 
Hopitaux de Paris. The disease is marked by redness, 
desquamation, and relapses. Its outbreak may or may 
not be preceded for one or two days by malaise and slight 
febrile movement. It begins on the trunk and invades 
the whole surface in a few hours or in two days. It is a 
diffused, uniform, intense, scarlatinal or somber-red 
eruption. There may be slight differences in the shade 
of color, or the redness may be punctate, or some pinhead- 
sized vesicles may develop upon it. Sometimes the 
eruption is limited to a certain portion of the body; 
sometimes the eruption is general, but not universal, 
normal islands of skin being found in the general redness. 

1 Ann. de derm, et de syph., 1890, i, 1. 



ERYTHEMA 299 

It conies out in patches that run together. There is 
generally redness of the mucous membrane of the mouth 
and fauces. There is no thickening of the skin nor 
infiltration of mucous membranes. The skin burns, 
and there may be itching. Exfoliation of the skin begins 
almost as soon as the eruption is out, commencing at 
the point of invasion. The desquamation is general, 
and may be furfuraceous, or abundant and in large 
plaques. Upon the scalp it is furfuraceous. The whole 
process may take but one or two days, or it may be pro- 
longed for a month or six weeks. The hair and nails 
may be shed. The tongue is furred, and may desquamate, 
but never presents the papilla? of scarlatina. After the 
beginning of the attack there is usually no fever, and 
the appetite is preserved. There may be albuminuria 
during the attack. The relapses, which are apt to occur 
after intervals of days, months, or years, are less pro- 
nounced and the patient's health is good in the interim. 

Etiology. — The cause of the disease is very often 
obscure. The first attack has been observed to follow 
exposure to cold, the application of mercurial ointment, 
or the action of some other irritant. But it is difficult to 
explain why from such causes relapses should occur. 
Besnier thinks that in some cases the cause is a poison 
developed within the individual. In this way he would 
explain some of the erythemas developing during an acute 
urethritis, which some observers claim may arise indepen- 
dently of the taking of copaiba. Scarlatiniform erythemas 
occur occasionally in septicemic conditions, in typhus 
fever, in malaria of children, in sewer-gas poisoning, and 
in various other conditions. 

Diagnosis. — Brocq considers scarlatiniform erythema 
as one form of dermatitis exfoliativa, but it is distinguished 
from it by an absence of evening rise of temperature, by 
having no permanent effect upon the health, by running 
a shorter course, and by the skin not being dry, con- 
tracted, and shrivelled. It differs from scarlatina in the 
mildness of its constitutional symptoms; by the course 



300 DISEASES OF THE SKIN 

of the eruption; by the absence of tumefaction of the 
fauces and the strawberry tongue; by the early desquama- 
tion; by not being contagious; and by its tendency to 
relapse. If there is any doubt as to the diagnosis, the 
patient should be isolated. It differs from measles in 
the absence of catarrhal symptoms and Koplik's spots 
in the mouth. It differs from erythematous eczema in 
an entire absence both of thickening and moisture; in 
being less itchy; and in its rapid course. 
Treatment. — The treatment is purely symptomatic. 

Erythema Exudativum. 

The second variety of erythema differs from erythema 
hyperemicum in the presence of an exudation into, not 
on, the skin, so that the patches are raised above the level 
of the skin, and in never involving the whole surface, but 
always occurring in circumscribed patches. It is an 
inflammatory disease. Its several varieties are alike in 
that the redness disappears under pressure, to return 
at once when the pressure is removed. It is probable 
that erythema nodosum is really but a part of erythema 
multiforme, as the two forms may be present at one time. 
But it is usually described apart, and although this may 
not be strictly accurate, it is convenient. 

Erythema (Exudativum) Multiforme, as its name 
indicates, is very multiform in its efflorescences. For a 
day or a few days before they appear there is some 
constitutional disturbance. This may be nothing more 
than slight malaise, the patient not feeling as well as 
usual. From these indefinite symptoms there are all 
grades, up to fever of 104° F., headache, gastric disturb- 
ances, and severe muscular and articular pains, like 
rheumatism. According to Besnier and Doyon, an ery- 
thema of the pharynx, or a pharyngitis, laryngitis, or 
bronchitis, often precedes or accompanies the outbreak 
of the eruption upon the skin. The eruption is most 
constantly seen upon the backs of the hands and feet, 



ERYTHEMA 301 

and here it commonly begins, though this is denied by 
Polotebnoff, to whom we are indebted for a most exhaus- 
tive and able study of erythema. 1 It also appears on the 
trunk and extremities more or less generally, coming 
out in crops, and preserving a rough symmetry. Some- 
times it may remain confined to a single region, as the 
backs of the hands. Sometimes it occurs on the mucous 
membranes, as of the mouth and eyes. It is usually 
most marked and abundant about the joints should 
they have exhibited rheumatic pains. It is rare not to 
find lesions upon the backs of the hands. With the appear- 
ance of the eruption there is a subsidence of the constitu- 
tional symptoms, though in many cases the patients are 
more or less definitely ill during the whole course of the 
disease. 

The eruption commences as a group of deep-red papules 
from pinhead- to pea-size, conical or rounded, and this is 
called erythema papidatum. The eruption may continue 
as such; or the papules may coalesce and form elevated 
patches, sharply marked against the sound skin; or they 
may enlarge to the size of tubercles, thus forming erythema 
tuberculatum. If they still continue to enlarge, they be- 
come depressed in the centre and ring-shaped, the peri- 
phery being deep red, while the centre is purplish. This 
is called erythema circinatum or annulare. Sometimes it 
happens that the ring still enlarges by. successive exuda- 
tions, and then there will be ring within ring, the outer 
one pink, the next red, the next purplish, thus forming 
an iris-like play of colors that has been termed erythema 
or herpes iris. Two rings near each other and enlarging 
will after a time meet at their peripheries, the points 
of contact will melt into each other and disappear, and 
there will form a large patch with a figure-of-eight or 
scalloped, raised border, and a flattened centre. This 
is called erythema marginatum. It may travel over a 
large part of the trunk or the circumference of a limb, 

1 Zur Lehre von den Erythemen, Hamburg, 1887. 



302 DISEASES OF THE SKIN 

leaving a fawn-colored pigmentation, which soon fades. 
Or two rings meet, and each breaks, and only a gyrate 
line is formed, to which the name of erythema gyratum 
is applied. Sometimes, though rarely, the exudation is 
so abundant that the epidermis is raised in the form of 
vesicles or bulla?. This is erythema vesiculosum seu bul- 
losum. Hemorrhage may take place into the bulla?. 

It is uncommon to find all these forms present at the 
same time, nor must it be understood that one form neces- 
sarily evolves into the other. The evolution may stop at 
any stage; most often at the papular stage. Neverthe- 
less, more than one form is usually seen, so that the term 
multiform is merited. Crocker says that in children mul- 
tiformity is less the rule, the constitutional symptoms are 
more pronounced, and if vesiculation occur the vesicles 
are more prone to become purulent and leave scars. 

The duration of the disease is from two to four weeks, 
but it may be extended by a succession of outbreaks for 
months or years. Very infrequently a given lesion may 
persist for weeks. This is erythema perstans. The erup- 
tion is attended by burning rather than itching, and some- 
times by a feeling of tension. Slight pigmentation may 
be left, but it is transitory. Desquamation may follow 
the eruption, but it is not common. In some patients 
there is a decided tendency to relapse at irregular inter- 
vals for years. In Prof. George Henry Fox's service at 
the Vanderbilt Clinic, I have seen a boy with a relapsing 
bullous erythema of the face and ears that had appeared 
at intervals during ten years. The bulla? were of large 
size, fully distended, and of irregular shape. They left 
depressed, pigmented cicatrices in some places. Similar 
cases have been reported by others, as, for instance, by 
Hardaway , who saw one case with relapses for four years ; 
and T. C. Fox, who saw two cases with a duration of six- 
teen years in each case. 

As complications of erythema multiforme, and espe- 
cially of erythema nodosum, have been reported endo- 
and pericarditis, meningitis, pleurisy, pneumonia, and the 



ERYTHEMA 303 

like; but it is better to regard these diseases not as com- 
plicating the erythema, but as the primary diseases of 
which the erythema is a phenomenon. 

Erythema Iris. — This disease was formerly regarded as 
a herpes, and is described in many text-books as herpes 
iris. Its other synonyms are hydroa, herpes circinatus, 
and hydroa resictdeax. It is. only a form of erythema 
multiforme. It is seen sometimes along with other 
manifestations of erythema multiforme, or withjierpes, 
though it usually occurs alone. It is located most often 
upon the backs of the hands and feet, and upon the arms 
and legs, but it may occur anywhere upon the skin as 
well as the mucous membranes. According to Crocker, 
there are two varieties of the disease, one with a central 
vesicle or a purplish depression surrounded by one or 
more whitish rings slightly raised up by effused fluid; 
the other with a central bulla with one or more rings of 
more or less discrete vesicles around it. Of these two, 
the first is the more frequent. 

The first variety begins as a small erythematous papule 
upon which a pinhead-sized conical vesicle forms in about 
twelve hours. The vesicle grows larger and flattens, but 
preserves a red areola. When about a quarter of an inch 
in diameter the fluid is absorbed in the centre, leaving a 
purplish depression; or only a ring of absorption occurs, 
so that there will remain a vesicle in the centre with a 
purplish zone about it, then a raised white ring, and 
around all a narrow pink areola. This play of colors 
gives the name of iris. The patch may reach the diameter 
of half an inch, and then undergo involution; or several 
patches may unite and form patches of one inch or more 
in diameter, and hemorrhage may take place into the 
bullae that may form. 

In the second variety, wmich is the hydroa vesicirfeu.r 
of Bazin, around a central bulla a ring of split-pea-sized 
vesicles forms, the vesicles being either discrete or touch- 
ing. A second or a third ring of vesicles may form out- 
side of these, the skin between them being a purplish 



304 DISEASES OF THE SKIN 

tint. The bullae and vesicles may leave scars. Crusting 
also takes place from the breaking or drying of the 
vesicles. 

The lesions of both varieties are more or less symmet- 
rical, though a patch may develop on one side several 
days before the other. The duration is from three to 
four weeks or longer. Relapses are common. Burning 
is usually pronounced, and there may be some itching. 
From this description it will be seen that the so-called 
herpes iris is really an erythema. 

Erythema Nodosum, also called dermatitis contusiforme, 
and erytheme nouveux (Ft.), is more common than ery- 
thema iris, but not nearly so common as erythema multi- 
forme. It is only a variety of erythema multiforme, as 
it may occur as a part of that disorder. In the vast 
majority of cases it occurs alone. Its prodromal symp- 
toms are substantially the same as those of erythema 
multiforme, but its rheumatic pains are more pronounced 
and nearly always present. There are also tenderness 
and pain over the tibia. After a few days of prodromata, 
round or, more often, oval, bright or rosy-red swellings 
appear over the tibiae, with their long axis vertical. 
These are from nut- to egg-size; raised; their borders merge 
gradually into the surrounding skin; they are painful 
and often exquisitely tender; firm at first, they may be 
semi-fluctuating afterward; and their color darkens to a 
red, then purple, and in undergoing absorption they 
present the appearance of a black-and-blue spot from a 
bruise. The color at first disappears under pressure, to 
spring back when the pressure is removed. The changes 
of color subsequently seen are due to the gradual ab- 
sorption of the coloring matters of the blood deposited 
in the tissues. There are usually not more than a dozen 
lesions, generally less. They are most frequently located 
over the tibiae, but may occur as well upon the arms, 
scapulae, thighs, and mucous membranes. They are 
roughly symmetrical. The duration of the disease is, 
like that of other erythemas, two to four weeks. 



ERYTHEMA 305 

Etiology. — The causes of erythema exudativum are 
not fully determined. It is probably due to some toxic 
condition of the blood, which may develop in the indi- 
vidual or be derived from without. It occurs more 
commonly in women than in men, and in young adults 
rather than in old people, while erythema nodosum is 
said to be most frequent in children. It is most frequent 
in the spring and autumn seasons, in which dampness and 
cold winds prevail, and sudden changes of temperature 
are common. The papular erythema is very often seen 
in recently arrived immigrants. Rheumatism has a 
well-marked causal relation to erythema nodosum, and, 
it may be, to the other forms. Syphilis seems to be an 
etiological factor of some weight in the production of 
erythema nodosum. Many cases seem to be due to 
systemic poisoning either by some infectious disease or 
by auto-infection. Some authorities are of the opinion 
that such cases should be separated from erythema 
exudativum, and propose the name of polymorphous 
erythema. It is seen with cholera, influenza, and the 
exanthemas; with indigestion, pregnancy, parturition, 
menstrual disturbances, kidney diseases, and various 
other internal or systemic disorders. Sometimes the 
disease seems to be a pure angioneurosis. Cases of 
erythema multiforme occurring with recurring attacks 
of gonorrhea have been reported. These appear as 
reflex angioneuroses without the ingestion of balsamics 
in the treatment of urethritis. Cases of erythema multi- 
forme not infrequently follow the ingestion of drugs; at 
least they are almost identical with it in appearance. 
Sometimes, according to Polotebnoff, it seems to be an 
abortive form of prevailing epidemics. Cases certainly 
should be watched carefully in connection with other 
symptoms, as they may be but part of the prodromata of 
some grave disorder. We have seen cases in which a 
well-marked erythema multiforme preceded for about ten 
days the outbreak of typhoid fever; the erythema then 
disappearing and the characteristic typhoid eruption 
20 



306 DISEASES OF THE SKIN 

coming in due course. Many of the subjects of erythema 
are debilitated. Individual predisposition probably plays 
an important role in the etiology of some cases, espe- 
cially in the relapsing ones. 

Pathology. — All forms of the disease show not only 
hyperemia, but also inflammatory effusion, both of fluid 
and leukocytes. Upon the amount of this fluid depends 
the character of the lesion. If small in amount, it will 
simply push up the epidermis into a papule or tubercle; 
if of larger amount, we shall have vesicles and bullae. 
There is also an escape of the coloring matter of the 
blood in the tissues (Crocker). 

Microscopically the papillary layer is seen to be the 
seat of the principal inflammatory changes; oedema, 
dilatation of the vessels, diapedesis, emigration of white 
corpuscles, and proliferation of the fixed tissue cells 
about the vessels. The covering of the bullae and vesicles 
may consist of the whole epidermis, or of only part of it. 

In erythema nodosum in addition to these changes, 
phlebitis of the larger subcutaneous veins has been found, 
and the frequent presence of white thrombi in the vessels. 
The epidermis rarely shows pathological changes. 

Diagnosis. — If the characteristics of erythema multi- 
forme are borne in mind, little difficulty in diagnosis will 
arise. These are the sudden occurrence of raised, bright 
or rosy-red lesions, located by preference upon the back 
of the hands and feet; the color of which fades away 
entirely under pressure, to return again when pressure is 
removed; and on disappearing they leave stains. It most 
resembles urticaria, but differs from it in having more 
stable lesions of more varied shape; in absence of wheals; 
in occurring particularly on the back of the hands and 
feet; and in burning rather than itching. The papular 
form differs from 'papular eczema in its chosen locations; 
in its burning rather than itching; in its papules being 
larger and never developing vesicles nor forming patches; 
in an absence of thickening of the skin; in disappearing 
completely under pressure; in tending to get well without 



ERYTHEMA 307 

treatment; and in leaving stains. The nodes of erythema 
nodosum differ from syphilitic gummata in occurring 
suddenly and not gradually. In syphilis the redness 
does not occur until after the node has existed for some 
time, and the nodes are not tender nor developed sym- 
metrically. Moreover, there would be other evidences of 
syphilis. 

Treatment. — Villemin 1 maintains that iodide of potas- 
sium, in doses of at least 30 grains (2) a day, is almost 
a specific, and will abort relapses. The experience of 
Besnier and others has not been in accord with that of 
Villemin. Qyinin, 20 to 30 grains (1.33 to 2) a day, salicy- 
late of soda in 15 grain (1) doses three or four times a 
day, and salol sometimes abort or check the disease. 
Adrenalin, 1 in 1000, has been recommended as a specific. 
The dose is 10 drops, which may be repeated every three 
or four hours, watching its effect. As this is a new 
remedy it must be used with care. Arsenic may be tried 
in chronic cases. 

The treatment is mainly symptomatic, and directed 
to relieving the constipation, regulating the diet, aiding 
digestion, ameliorating rheumatism, or toning up the 
system. In obstinate cases the patient had best be kept 
in bed. 

Locally any alkaline lotion will afford relief, such as 



-Pulv. calamin. prsep., gr. xl 2 

Zinci oxid., 3ss 2 

Liq. calcis, ad §ij ad 64 



M. 



Or, 



R* — Liquor plumbi subacetatis, ttlxv 1 

Aqua?, 5J 32 M. 



Or, lead-and-opium wash, hamamelis, or other evaporat- 
ing solutions. Ointments should be avoided, as they 
do no better than lotions and are disagreeable to use. 
Sometimes a simple dusting powder will do as well as 
anything. 

1 Gaz. hebdom., May 24, 1886. 



308 DISEASES OF THE SKIN 

In erythema nodosum the patient should be kept in 
bed. Lotions are often more agreeable to the patient 
when used warm. Salicylic acid or salicylate of soda by 
the mouth may afford relief to the sometimes intense 
pains. Regulation and simplification of the diet, and the 
administration of diuretics or tonics, according to the 
nature of the case, will do good in the disease as seen in 
immigrants. 

Prognosis. — The disease tends to spontaneous cure. 
Relapses may occur, though they are by no means. the 
rule. Exceptionally the disease may run a protracted 
course, but recovery may be expected. 

Erythema Elevatum Diutinum. — See Granuloma annulare. 

Erythema Figuratum Perstans. — According to Wende 1 
this is a rare disease that is not a form of erythema 
multiforme, It begins with scattered, isolated papules, 
which tend to fade at the centre while extending periph- 
erally, thus forming circinate erythematous outlines. 
The outer half of the advancing margin is smooth and 
slightly raised, the inner margin being scaly, which is 
a marked feature of the disease. Sometimes it leaves 
slight scaliness and pigmentation of the surface over 
which it has past. The larger lesions may be the size 
of a twenty-five-cent piece, the palm of the hand, or 
larger. The rings may be of circinate, annular, discrete, 
confluent, gyrate, or zigzag form. They may increase 
rapidly or slowly in size. Exacerbations may occur 
three or four times a year, the eruption, as a rule, not 
entirely disappearing in the intervals. There may or 
may not be subjective symptoms. 

The disease occurs both in children and adults. Other- 
wise the patients are in seemingly good health. The 
cause of the disease is not determined. It is probably 
due to some intestinal intoxication. Treatment is 
unsatisfactory, as the disease is quite sure to relapse. 

1 Jour. Amer. Med. Assoc, 1908, li, 1936. 



ERYTHEMA INDURATUM SCROFULOSORUM 309 

Erythema Induratum Scrofulosorum is a disease first 
described by Bazin as erytheme indure des scrofuleux. 
It consists in an eruption of nodular lesions that may 
remain deep seated for a considerable time, so that they 
can be made out only by palpation. There may be but 
one lesion or many. In the majority of cases the disease 
is bilateral. After a while the overlying skin becomes 
red, and later violaceous, and the lesions resemble those 
of erythema nodosum. In size they vary from that of a 
hazel-nut or larger on the legs, to smaller on the fingers. 
They are round or ovoid in shape and doughy to the 
touch. They are usually few in number and discrete, 
but may be numerous and confluent, and form large 
brawny infiltrations. They are chronic and indolent 
in their course, and may undergo involution, or sup- 
purate or necrose en masse. Polycyclic ulcers may form 
which heal slowly with scarring, or remain sluggishly 
open. A dark stain or a scar may be left on the disap- 
pearance of the lesions. There may or may not be pain 
or tenderness. They are located most often on the 
calves of the legs in young people, especially in young 
women of poor general health and circulation, who 
stand a great deal and who suffer from chilblains in 
winter, but may occur in others who present none of 
these peculiarities. They are prone to relapse at certain 
seasons. 

Pathology.— Inflammatory and degenerative changes 
affect the vessels, and giant cells are present in large 
numbers. The lesion has been compared in its appear- 
ance to a necrotic tubercle. No tubercle bacilli have 
been found in them by investigators excepting Kuz- 
nitzky, 1 who also obtained positive reactions to tubercle 
bacilli inoculations, and benefit from their use. 

Diagnosis. — They differ from erythema nodosum in 
their more circumscribed form, firmer consistence, 
darker color, deeper seat, absence of tenderness, tendency 

1 Archiv. Dermat. u. Syph., 1910, civ, 227 



310 DISEASES OF THE SKIN 

to ulcerate, and more protracted course. Syphilitic 
gummata are not bilateral, and usually other symptoms 
of syphilis can be found. 

The treatment consists in rest in bed, elevation and 
compression of the legs, and general tonics. Inocula- 
tions with Koch's old tuberculin in small doses are often 
advisable. If there are ulcers they should be treated like 
any common ulcer. 

Erythrasma. — A contagious parsitic disease of the skin, 
occurring especially in the groins and axilla? in the form 
of sharply defined, brownish-red, desquamating patches, 
bordered by a fringe of broken and partly detached 
epidermis (Foster). 

Symptoms. — The disease begins as little reddish-brown 
or orange-red points that soon become lentil-sized macules, 
which coalesce in a patch the size of a silver dollar, or the 
hand. Several patches join together, so that large sur- 
faces may be involved. The patches are oval or disk- 
shaped, or irregular in outline. The color of the patches 
is orange, red, yellowish, or brownish, or, in the folds of 
the skin, pale red. Their outline is sometimes marked 
by a raising of the epidermis. Their surface is dull- 
looking, and feels less smooth than normal and shows 
slight furfuraceous desquamation. They are quite 
tenacious, cannot readily be rubbed off, and show little 
tendency to spontaneous recovery. There may be slight 
itching. They are located in the situations where in- 
tertrigo is liable to occur, such as the axillae, groins, and 
where the scrotum comes in contact with the thighs. 
The latter situation is declared by Besnier to be nearly 
always the original site of the disease. From these 
favorite locations the disease may spread to the chest, 
abdomen, or thighs. Besnier 1 met with a case involving 
the thigh down to the knee. We have seen one case in 
which nearly all the skin was involved. 

1 Jour, de Med. et do Chirurg. prat,, 1883, liv, 351. 



ERYTHRODERMIA, CONGENITAL ICHTHYOSIFORM 311 

Etiology. — The disease occurs most often in men, 
and never in children. It is rarely seen in this country. 
It is due to a parasite called the microsporon minutissi- 
mum, which is described by Balzer 1 as consisting of long, 
wavy mycelia, that are rarely branched; and of very 
fine spores. High powers of the microscope are necessary 
to see them. They are located exclusively in the corneous 
layer of the skin. He regards them as a common form 
of parasite that produces the disease in some people only 
on account of the peculiar fermentation of their skin 
secretions. 

Diagnosis. — The disease resembles chromophytosis, 
eczema marginatum, and chloasma. It differs from 
chromophytosis in the darkness of its color; in the ab- 
sence of distinct, rather large scales that can be lifted by 
the nail; in its location, sparing the trunk, except by 
extension; and in the character of the microscopic 
appearances. From eczema marginatum it is distinguished 
by an absence of all inflammatory symptoms, ring- 
shaped lesions, and festooned margins, by not being more 
pronounced at the periphery than at the centre, and by 
the microscopic appearances. From chloasma it differs in 
being a parasitic and not a pigmentary disease, in the 
change it causes in the feel and texture of the skin, and 
in the effect of treatment. 

Treatment.- — It is curable by the same means as is 
chromophytosis, namely, wiping off the skin with pure 
alcohol followed by a saturated solution of the hypo- 
sulphite of soda; tincture of iodin; pyrogallol; chry- 
sarobin; bichloride of mercury; or sulphur. It is more 
obstinate than is chromophytosis, and quite as prone 
to relapse unless thoroughly eradicated. 

Erythrodermia, Congenital Ichthyosiform. — This disease 
is described by Brocq 2 as a chronic generalized redness 
of the skin which may be so slight as hardly to attract 

1 Ann. de derm, et de syph., 1884, v, 597. 

2 Annal. derm, et syph., 1902, iii, 1. 



312 DISEASES OF THE SKIN 

attention, or so intense as to resemble pityriasis rubra or 
pemphigus foliaceus. There may be a marked hyper- 
keratosis shown as an exaggeration of the papillae of 
the neck and folds of the large joints, giving an appear- 
ance like acanthosis nigricans without the black color. 
There may be keratosis of the palms and soles; abun- 
dant pityriasis of the scalp; deformity of the nails, and 
bullae. The disease is congenital. The etiology is obscure. 
Diagnosis. — It differs from ichthyosis in its red color, 
its papular formation, and its involvement of the joints; 
from pityriasis rubra pilaris by being congenital, involv- 
ing the whole surface at once, by the different character 
of its scaling, and by absence of papular formations about 
hair follicles; from pityriasis rubra by being congenital, 
by not affecting the general health in spite of its chroni- 
city, and by the character of its scaling. Treatment is 
of no avail. 

Erythromelalgia is a nervous disease characterized by 
the appearance of a persistent patch of congestion, often 
on the sole of the foot, attended with swelling, itching, 
and pain (Foster). Hyperidrosis is often marked. It is 
a symptom in various grave diseases of the brain and 
spinal cord. 

Esthiomene. — This is a disease of the vulvo-anal region 
that was described by Huguier, 1 and about which there 
is a good deal of uncertainty. It has been variously 
considered as a form of lupus, syphilis, elephantiasis, 
and epithelioma. "It is characterized by a leaden or 
violaceous hue of the parts, and their simultaneous 
alteration of shape, induration, thickening, ulceration, 
destruction, hypertrophy, and infiltration, so that the 
orifices and canals of the vulvo-anal region may be at the 
same time ulcerated, enlarged, and constricted, and its 
grooves and cutaneous and mucous folds exaggerated, 
thickened, and the seat of more or less extensive and deep 

1 Mem. de l'Acad. de Med., 1869, p. 507. 



FAVUS 



313 



ulcerations and cicatrices; without pain, without directly 
threatening life, and for a long time without affecting 
the constitution." (Foster.) 

Farcy. — See Equinia. 

Favus. — Synonyms: Porrigo lupinosa seu favosa seu 
lavalis seu scutulata; Porrigophyta ; Tinea favosa seu 
vera seu ficosa seu lupinosa seu maligna; Trichomykosis 



Fig. 3 


3 






{ ' J 


. 


i i* s 






* \* 





Favus. (Jackson and McMurtry.) 

or Dermatomycosis favosa; (Fr.) Teigne faveuse, Teigne 
du pauvre; (Ger.) Erbgrind: Crusted or honey-comb 
ringworm, Scall head, True porrigo. 

A contagious vegetable parasitic disease due to the 
Achorion Schoenleinii, and characterized by the presence 



314 DISEASES OF THE SKIN 

of discrete or confluent, circular, pale sulphur-yellow 
cupped crusts, or by asbestos-like masses of grayish 
friable crusts; by loss of hair producing irregularly shaped, 
disseminated, red, bald patches; by permanent atrophy of 
the scalp; and by running a chronic course. 

Fig. 34 




Favus of knee. 

Symptoms. — Favus affects both the scalp and the non- 
hairy skin as well as the nails and mucous membrane. 
We shall first describe it as it affects the scalp. A lesion 
of continuity, however slight, is probably necessary for 
contagion to take place. In a case of favus in a newborn 
child the period of incubation was found to be from six 
to eight days. It begins either as one or more scaly 
erythematous spots; or as minute yellowish puncta; or 
as a group of vesicles smaller than those met with in 
ringworm. These develop into small sulphur-yellow 
cupped crusts about the hairs. When the case is seen by 
the physician the early stage is usually passed, and he will 
find that the hair is dry and lusterless, and has fallen out 



FAVUS 315 

in places, leaving irregularly shaped bald patches, of all 
sizes, and of pronounced red color. Upon both the bald 
patches and the parts still covered with hair the sulphur- 
yellow cup- or saucer-shaped crusts will be found, with 
raised or rounded edges, and with one or several hairs 
growing out of the middle of them. There will be more 
or less scaling, and, if the disease be of some age, thick 
mortar-like crusts of grayish color. In some cases when 
first seen it may be impossible to find the characteristic 
crusts — scutula as they are called — they being obscured 
by the mortar-like masses. In some cases the scutula are 
wanting. If we approach near enough to the patient, we 
will appreciate a peculiar odor variously described as that 
of mice, straw, or of a menagerie. 

The crusts, or scutula, are situated about the hair 
follicles. They are from pinhead- to split-pea-size, 
according to age. At first they are covered with a thin 
layer of epidermis, but later the edges are free. When they 
are picked off they leave a moist depression which soon 
fills up, or a pustule, or an atrophied spot. The color is 
pale or sulphur yellow, or, if of long standing, it may be a 
dirty or greenish yellow. The crusts are discrete and 
disseminated or grouped; sometimes they coalesce; they 
are firm to the touch, and when crushed between the 
fingers impart a feeling of crumbling like mortar. There 
is a zone of slight redness about them. Though they may 
not be seen at the first examination, if the scalp is cleaned 
off and left to itself they will form in the course of two 
or three weeks. The baldness is rarely in well-defined 
patches. The patches may be few in number, or so 
numerous that the hair occurs only in islands. At first 
their color is inflammatory red; later they become white 
and atrophic in appearance. The baldness is permanent. 
The hair is dry from the first; later it becomes brittle 
and splits longitudinally; but it is never so easily broken 
as in ringworm, and can easily be pulled out with its 
roots. There is itching of the scalp. That is the only 
subjective symptom. Pustulation does not belong to the 



316 DISEASES OF THE SKIN 

disease, but may be an accidental complication. The 
cervical glands are often enlarged; but do not break 
down. Its course is very chronic, and it does not tend 
to spontaneous recovery as does ringworm at the approach 
of puberty. Other complications that may arise are 
pediculosis, eczema, and enlargement of the cervical 
glands. 

Occurring upon non-hairy parts favus undergoes mate- 
rially the same development and forms the characteristic 
cups. Sometimes it will take the circular form of a 
ringworm with the formation of vesicles, and resemble 

Fig. 35 



'/ 




Favus of hand, showing scutula. Side view. 

it very closely, only that the cups will be sure to develop 
somewhere. The scutula develop around the lanugo 
hairs. There may be only one patch of favus or a large 
part of the body will be covered by the fungous growth 
in the form of sulphur-yellow cupped crusts and asbestos- 
like masses. On the non-hairy parts the disease is easier 
of cure than on the scalp, and is not so apt to leave scars'. 
In a single case, that of Kaposi, the favic fungus was 
found implanted upon the mucous membrane of the 
stomach. 

The nails may be affected, either in the form of ony- 
chitis beginning at the side of the nail, hardly distin- 



FAVUS 317 

guishable from the same disease developed from common 
causes; or in having a scutulum develop in the nail bed 
and show through the nail. This is rare. The occurrence 
of favus upon the head will give a clue to the origin of 
the onychitis. 

Etiology. — The disease is due to the implantation and 
growth of the Achorion Schoenleinii primarily in the 
scalp and secondarily in the hair. It is contagious, 
either directly from individual to individual, or through 
wearing the cap or using the hair-brush, and the like, 
of some fa vie person, but not so much so as is ringworm. 
It used to be rare in New York City, but on account of 
its being constantly imported from Europe, where it is 
very common in certain sections as in Hungary and 
Poland, the disease is on the increase, and cases occur in 
native Americans, mostly of foreign parentage. Though 
children between the ages of six and fifteen years are 
more commonly affected than are adults, it is by no 
means uncommon to see it in full activity in people 
well advanced in life. It has been asserted that the 
strumous diathesis predisposes to favus, but this is 
doubtful. Like all other parasites, it requires a certain 
soil upon which to grow, and does not affect all skins. 
Neglect of personal hygiene favors its spread. It is a 
common disease in mice, and may occur in rabbits, 
dogs, cats, and fowls, and thus be a source of contagion 
for the human race. 

Pathology. — The cups are composed almost wholly 
of the fungus, which consists of flat, narrow, branching 
and inosculating mycelial threads g-J-Q of an inch in 
diameter, and of pale-gray color; and of small spores of 
round, oval, flask, or dumb-bell shape, and of a pale- 
greenish color (Figs. 36 and 37). The spores gain access 
to the skin by the orifices of the hair follicles, and, after 
remaining there undisturbed, begin to grow in the upper 
part of the hair sac, and between the superficial layers 
of the epidermis, and subsequently invade the hair, 
growing in its cortical substance. The cup may be formed 



318 



DISEASES OF THE SKIN 



either by the sinking in of the more central portion of the 
mass, or on account of the central portion being attached 



Fig. 36 




Favus of hand. Front 



Fig. 37 



^k/T'" ' 




Achorion Schoenleinii. (After Kaposi.) 



FAVUS 



319 



to the hair so firmly that it cannot so readily give way 
and bow out under the pressure of the growing fungus 
as do the parts farther away from the hair. The atrophy 
of the skin is largely due to the pressure of the growing 



Fig. 38 




Achorion Schoenleinii in hair shaft and follicle. (After Kaposi.) 

fungus, which is powerful enough to destroy the cranial 
bones of mice; and in part to the inflammation of the skin 
produced by the presence of the fungus. 

There are at least four other species of the Achorion 
which produce favus in animals, and very exceptionally 
in man. These are achorion galling; oosporia canina of 



320 DISEASES OF THE SKIN 

Sabrazes — Constantin; achorion Quinckeanum of the 
mouse; and achorion gypseum of Bodin. 

Diagnosis. — Most cases of favus are easy of diagnosis; 
the sulphur-yellow cupped crusts; the asbestos-like gray- 
ish mass; the red, atrophic bald spots, with tufts of dry 
and more or less kinky hair in them; and the peculiar 
odor, being so well marked. Ringworm has none of these 
features. Moreover, it occurs in the form of circular 
circumscribed, only partially bald patches covered with 
grayish scales, in moderate amount; has characteristic 
nibbled-off "stumps" of hair; and under the microscope 
we find the spores less abundant, smaller, and more 
uniformly round than in favus. It must .be confessed, 
however, that without the clinical features of one or the 
other disease, none but a most expert microscopist could 
make the diagnosis in a doubtful case by the microscope 
alone. In eczema baldness is very rare, and we will 
usually find a characteristic patch of the disease behind 
the ear; its crusts are greenish and tenacious, not gray 
and friable; the hair is matted by the sticky exudation; 
and if discrete impetigo lesions are present, they will 
contain pus, and not be solid like the favus crust. Leav- 
ing the scalp alone for a time will decide the matter, as 
scutula will be sure to form if the disease is favus. Sebor- 
rheal dermatitis causes a general thinning of the hair; 
the scalp is not atrophic; there are no scutula, and no 
achorion in the hair and scalp. Lupus erythematosus 
resembles favus only in producing atrophic red spots. 
There will usually be patches of the disease elsewhere, 
and its whole course is different. Psoriasis does not cause 
atrophic bald spots, and rarely occurs on the scalp alone. 
Alopecia areata presents more or less circular bald areas, 
but these are white, smooth, and of normal texture, 
and there is no fungous growth in the hair. Alopecia 
from syphilis in its secondary stage resembles favus 
more closely than any other disease of the scalp; but it 
occurs primarily at a later age than does favus, it comes 
on more suddenly, there is no history of crusts, nor 



FAVUS 



321 



cicatricial alteration of the scalp, and there will be 
other evidences of syphilis on the body, and (especially 
in women) the broken arch of the eye-brows. Folliculitis 
decalvans bears a resemblance to favus when the cups 
and crusts have fallen. In it there are no tufts of dry, 
wiry hair; the hair comes out less easily when plucked; 
it is a disease of adults; and no achorion is found in the 
hairs. It is also a follicular disease, individual inflamed 
follicles being most always found. 

Treatment. — In the treatment of the disease we need 
three weapons — patience, perseverance, and parasiticides. 
Before using the last we should always epilate, pulling 
the hair out systematically from day to day, so that 
eventually all the hair of the scalp is plucked. To do this 
we may use the epilating forceps (Fig. 39); or Kaposi's 




Piffard's epilating forceps. 



method of grasping the hair between the thumb and a 
spatula or piece of stiff cardboard held firmly in the 
hand; or, in dispensary practice, we may employ epilating 
sticks, made, according to Bulkley, of 



Cerae fiavse, 


5ij 


8 


Laccae in tabulis, 


3iv 


16 


Picis burgundicae, 


3x 


40 ! 


Gummi damar., 


Siss 


48 



M. 

These ingredients are to be melted together, and then 
moulded into sticks a half-inch or more in diameter. 
They are to be used by melting the end, and when warm 
applying it to the hair with a sort of boring motion. 
When cold they are to be suddenly twisted off, when, 
of course, they will bring many hairs with them. The 
"calotte," or pitch-cap, used to be employed for this 
purpose, but was given up because it caused the death of 
several patients. Kaposi's method is the best of all. If 
21 






322 DISEASES OF THE SKIN 

the head is greatly crusted, the crusts may be scraped off 
with a curette or cleaned off by means of soaking the scalp 
with oil for a day or two, and then washing with soap and 
water. For an oil we can use sweet oil, sweet almond 
oil, or cotton-seed oil, with 3 per cent, of carbolic or 
salicylic acid. The use of these oils should be continued 
throughout the whole course of the disease to prevent 
the spread of the fungus upon the scalp of the patient 
and of other people. After the first washing we should 
allow the scalp to go unwashed for twenty-four hours, 
so as to permit the full action of the parasiticide. 
After the crusts are removed the diseased hairs should 
be pulled out. 

After the cleansing and the epilation the parasiticide 
must be rubbed and worked into the scalp. Of these there 
are many from which to choose. An ointment consisting 
of a drachm (4) of the crystals of iodin in an ounce (32) 
of goose grease is one of the best. It cannot be used 
over all if the whole scalp is involved, but in sections. 
Sulphur ointment is efficacious, if properly and per- 
sistently used. Other ointments are thymol, naphtol, 
resorcin, chrysarobin, and pyrogallol in 5 to 10 per cent, 
strengths, and those of the ammoniate or yellow sulphate 
of mercury. The ointments are to be firmly rubbed into 
the scalp every day after washing with soap and water. 
Or solutions may be employed, as bichloride of mercury; 
2 grains to the ounce of ether or alcohol; the oleate 
of mercury or copper, 10 to 20 per cent.; tar; oil of 
cade; creosote in ether or alcohol; sulphurous acid in full 
strength; salicylic acid, 5 per cent, in oil; or tincture of 
iodin, or resorcin 1 drachm (4) to the ounce (32) of lanolin 
and oil. Iodin, according to Sabouraud, should be used 
only once a month; in the meantime the scalp should be 
washed alternately with alcohol and camphorated alcohol, 
or with a solution of salol, 1 .5 per cent., and kept constantly 
anointed with iodin ointment. After a month the epila- 
tion and the iodin are to be repeated. Hydronaphtol 
plaster is said to do good service in favus, used according 
to the method described under Trichophytosis, which 



FAVUS 323 

see. Peroni 1 recommends spraying the head with acetic 
acid used in an atomizer, after covering any excoriated 
points with diachylon ointment on a piece of cloth. 
At first the scalp feels cold. Hyperemia follows which 
lasts about forty-eight hours and disappears, leaving 
slight desquamation. When the hyperemia lessens the 
acid is to be again used. When there are no excoriations 
the head is to be washed every morning and evening 
with water and corrosive sublimate soap. 

Besnier and Doyon 2 recommend as a preparatory 
treatment for favus that the hair be cut off from and 
around all the patches, and the whole head covered for 
two or three hours with equal parts of soft soap and lard. 
This is to be washed off with warm water, and the head is 
to be kept covered dining the night with a cap of rubber 
or other impermeable cloth. The next morning the head 
is to be washed perfectly clean, bathed with a solution 
of boric solution (25 to 1000) and covered with borated lint 
soaked in the following solution: 



-Sodii salicylate 


5uj 




12 


Sodii bicarbonati, 


Siiss 




10 


Aquae, 


ad Oij 


ad 


1000 



M. 

Over all comes the impermeable cap. After a few days 
the dermatitis will disappear and the scalp will be clean, 
and then epilation must be practised, the hairs being 
pulled not only from the patches, but for about a half- 
inch about them. Epilation is to be repeated every week 
until no longer any trace of redness about the hairs exists, 
and the head is to be kept covered with the impermeable 
cap. Every evening the whole head is to be rubbed 
with antiparisitic ointment, such as: 

1$ — Bals. Peruv. vel., 

01. cadini, 2 to 5 parts. 

Ac. salicyl., 

Resorcin., aa 1 to 5 parts. 

Sulph. prrecip., 5 to 15 parts. 

Lanolini, 

Vaselini, 

Adepis, aa p. e. ad 100 parts. M. 

1 Ann. de derm et de syph., 1891, ii, 797. 

2 Kaposi: Mai. de la Peau, French ed., Paris, 1891. 



324 DISEASES OF THE SKIN 

Every morning the whole scalp is washed with tar soap, 
and each favic patch is soaked with the following: 



i. — Alcoholis (90 per cent.), 


100 parts 


Ac. acetic, (crystals), 


\ to 1 part. 


Acid, boric, 


2 parts 


Chloroformi, 


5 parts 



M. 

Then each patch is to be accurately covered with mer- 
curial plaster. 

Epilation is rapidly and painlessly effected by x-rays. 
It is possible to cure a case by this means, but it is better 
to use some antiparasitic after the hairs have fallen. The 
method of using .r-rays is the same as in ringworm, 
to which the reader is referred. 

Favus of the non-hairy parts of the body usually yields 
readily to the removal of the crust and the use of a 
parasiticide. 

Favus of the nail may be treated by the constant 
application of ^a mercurial, resorcin, or hydronaphtol 
plaster. If the disease is limited to one or two points, 
they may be cut down upon and the remedy applied 
directly. Sometimes it may be necessary to remove the 
whole nail. 

After a case of favus has been faithfully treated for a 
number of weeks and looks as if it were well, it should be 
let alone and watched carefully for a long time. Any red 
point that appears is evidence that the disease is cropping 
up again, and should be immediately attacked. 

Pkognosis. — The prognosis is good, provided the case 
is faithfully and energetically treated. Relapses will 
surely occur if any of the fungus remains in the scalp. 
A cure takes months or years to effect by the older 
methods, while the use of x-rays greatly expedites the 
cure. The scars from favus are permanent. Favus of 
the nail is especially rebellious to treatment, and may 
cause permanent destruction of the nail. 

Feigned Eruptions. — See Dermatitis factitia. 
Fever Sore. — Herpes facialis. 



FIBROMA 325 

Fibroma. — Synonyms: Fibroma molluscum; Mollus- 
cum fibrosum; Molluscum simplex; Molluscum pendu- 
lum; Recklinghausen's Disease; Neurofibroma. 

Fibromata are soft tumors of the skin that are com- 
posed of a hyperplasia of the connective tissue as well as 
the subcutaneous tissues, and occur in A'arious shapes, 
colors, and sizes. The most commonly encountered 
form of fibroma is 

Molluscum fibrosum. — This may be of the color of the 
skin, or pinkish or even brownish or brownish red; most 
commonly it is of normal skin color. It may be rounded, 
flattened, sessile, or pedunculated, but always raised 
above the level of the skin. It may hang down like a 
polypus. The skin over it feels soft and of normal text me, 
or it may be thickened or atrophied. Hairs sometimes 
grow from it. There may be but one or two present, 
or there may be hundreds of them so that the body is 
strewed over from head to foot with the variously shaped 
tumors. The trunk is the most common location for 
fibromata, but they may occur on all parts and involve 
even the mucous membranes (Fig. 39). They give 
rise to no inconvenience except on account of their 
size, which sometimes may be that of a child's head or 
larger. Their usual size is from that of a cherry to that 
of a walnut. Many of them show a slow growth, while 
many are stationary, and some may undergo involution. 
Comedones of large size may accidentally form in some 
fibromata. The larger ones may ulcerate. All of them 
feel soft, while the larger ones may be elastic to the touch. 
When they hang down in the form of large skin folds 
which have undergone hypertrophy, the term fibroma 
pendulum is applied to them. Dermatolysis (which 
see) has been considered a form of fibroma. According 
to some authorities, fibrous moles and soft warts are 
but forms of fibroma. 

Scattered among the tumors there may be irregular 
patches of brown pigment, and more or less freckles, 
hairy moles, and vascular nevi. The skin may be coarse. 



326 



DISEASES OF THE SKIN 



There is another form of fibroma to which the name 
Achrochordon is applied. They occur as small, soft pedun- 
culated, vascular, and mole-like lesions upon the face, 
shoulders, and elsewhere in elderly people whose skin is 



Fig. 40 




Multiple fibromata. 1 



degenerated. They often take the form of little hernia- 
like sacs of skin when their contents have been absorbed. 
There is also a hard variety of fibromata called des- 
moids. These occur as round or oval, compact, smooth 
nodules, from hemp-seed to pea size. 

1 From a photograph of a case of Dr. E. T. Tappey, of Detroit. 



FLESHWORMS 327 

Etiology.— Fibromata usually appear in childhood, 
though they may not do so until later in life. They are 
sometimes hereditary, and are often seen in several 
members of the same family. They tend to increase with 
advancing age— that is, they are not so large or numerous 
in children as in adults. Children with multiple fibro- 
mata, Recklinghausen's type, are often stunted both 
physically and mentally. By some authorities they are 
regarded as related to neurofibromata. 

Pathology. — The early tumors and the central por- 
tion of the older growths, consist of embryonic connec- 
tive tissue. The density of the tumors increases toward 
the surface, the larger growths being provided with a 
firm fibrous sheath. 

Diagnosis. — Molluscum fibrosum differs from mollus- 
cum cantagiosum by not having a central depression, and 
by being of the normal color of the skin. They are also 
usually far more numerous. From fatty tumors they 
differ in not being lobulated, and in being pedunculated 
and less flat. Sebaceous cysts are not so numerous, and 
their contents can be squeezed out to a large extent, 
while fibromata are solid. 

Treatment. — They may be snipped off with scissors 
or tied off with ligature if pendunculated. If non- 
pedunculated, they may be destroyed by electrolysis 
or excised. If of- large size, they may be excised. The 
galvanocautery may be used to destroy any form. 

Flea-bites caused by the pulex irritans, occur in the 
form of small red puncta which may or may not be in the 
centre of wheals. They sometimes bear a close resem- 
blance to urticaria that has been scratched. The grouped 
arrangement of the lesions and the limited areas upon 
which they occur suggest their origin. A certain amount 
of protection is afforded by dusting the inside of the 
clothing with pyrethrum powder. The irritation may be 
relieved by the use of carbolic acid and alkaline lotions. 

Fleshworms. — See Comedo. 



328 DISEASES OF THE SKIN 

Fluxus Sebaceus.— See Seborrhea. 

Folliclis.— Synonyms: Lupus erythemateux dissemine; 
Folliculites disseminees des parties glabres; Acne vario- 
liformis of the extremities; Hydrosadenite disseminee 
suppurative; Necrotising chilblains; Granuloma inno- 
mine; Toxi-tuberculides papulo necrotiques; Granuloma 
necrotica. 

Symptoms. — Considerable doubt exists as to the exact 
status of the disease. It is probable that it is the same 
as the small pustular scrofuloderm described by Duhring. 
The eruption consists in flattened pinhead, rounded 
papules that develop deep down in the derma. They 
increase in size to that of a lentil. Their color is dark 
red or violaceous. They are firm to the touch and sur- 
rounded by a red areola. Pustules form on top of them, 
and these dry into crusts which are adherent, and when 
removed disclose a small but deep ulceration. Pinhead 
pit-like cicatrices are left which may have pigmented 
areolae about them for a time. The papules abort some- 
times and leave no trace on the skin. Their evolution 
takes four or five weeks, and the lesions come out in 
crops, so that all varieties are present at the same time. 
There is no definite grouping nor subjective symptoms 
excepting, sometimes, tenderness or pruritus. 

The disease affects all parts of the body, but is most 
abundant on the limbs, upon which it commences, espe- 
cially on the hands, feet, elbows, and kness. On the ears 
and fingers they appear like chilblains. Sometimes the 
disease is confined to the hands and feet. When the dis- 
ease spreads it does so by continuity. Its spread may 
be continuous or interrupted. It comes out sometimes 
at certain seasons of the year, as spring or autumn. 

Etiology. — Most cases occur in those who have a poor 
circulation, as shown by a dusky blueness of the hands 
and feet, and in children or young people. It is seen 
with lupus, and in those who present evidence of tuber- 
culosis or scrofuloderma. It is described by the French 
as a tuberculide. 



FOLLICULITIS DECALVANS 329 

Pathology. —It is regarded by some as a granuloma. 
According to Hartzell 1 it begins with inflammatory 
changes in and around the bloodvessels in the deeper 
portions of the coriurn, and gradually extends to the 
surface. There is an abundant round-celled infiltration 
about the vessels with thickening of their walls and 
obstruction or obliteration of their lumina, followed by 
necrosis of the tissue of the corium. Tubercle bacilli 
have not been found in them. 

Diagnosis. — Folliclis is allied to acne necrotica. It 
differs from it mainly in location, the latter preferring 
the face. It differs from acne in its distribution, slug- 
gishness, variola-like scars, and absence of comedones. 

Treatment. — Crocker advises the application of a 
mercurial plaster before suppuration has occurred. After 
that has occurred the central core is to be removed and 
the pit washed out with a 1 in 40 carbolic acid lotion. 
Everything must be done to improve the general health 
as in tuberculosis, and to stimulate the local circulation. 
Whitfield recommends calcium lactate, and nitroglycerin , 

Folliculitis means an inflammation of the hair follicles. 
When the hairs involved are those of the beard we have 
F. barbae, or sycosis (which see). The hair follicles on the 
extremities, especially of the legs, may become inflamed 
on account of some irritant applied to the skin. One 
form of this is tar acne. In workers in oil or paraffin 
it is no uncommon thing to see each hair on the legs, espe- 
cially the thighs, standing in the centre of a red papule 
or pustule. The cure consists in removing the cause, in 
cleansing the parts, and the application of an alkaline 
soothing lotion. 

Folliculitis Decalvans. — Synonyms: Alopecia cicatri- 
sata (Crocker), or orbicularis (Neumann), or circum- 
scripta, or atrophicans; pseudo-alopecia atrophicans; 
pseudo-area ; Ulerythema sycosiforme ; Perifolliculitis 

i Med. Rec, 1906. lxix, 1012. 



330 DISEASES OF THE SKIN 

cicatrisans; Acne decalvante on pilaire cicatricielle 
depilante (Besnier); Alopecie innominee (Besnier). 

These, and still other names have been given to a 
group of diseases of hairy parts characterized by: (1) A 
follicular and perifollicular inflammation; (2) a complete 
destruction of the hair follicles causing absolute bald- 
ness; (3) the formation of cicatricial tissue; and (4) a 
tendency of the lesions to agminate or group. It occurs 
principally in three forms: (1) Alopecia cicatrisata; (2) 
Depilating folliculitis, and (3) Ulerythema sycosiforme. 
The last will be described under Sycosis. 

Alopecia Cicatrisata. — This is the alopecie innominee 
of Besnier, the pseudopelade of Brocq, and the alopecia 
orbicularis of Neumann. 

Symptoms. — The disease begins insidiously without 
pain or perceptible inflammation. There may be sebor- 
rhea, pityriasis, or slight pruritus of the scalp. Inspection 
of the scalp reveals a number of small bald spots, which 
may be of faint rosy color, but usually are white, smooth, 
and ivory-like. Any part of the scalp may be affected 
but the vertex is so most often. The disease may begin 
at one point, but most often many places are affected, 
the hair falling from them. There may be only small 
patches, or large ones with satellites. When there are 
only small patches, the scalp will appear cribbled with 
them. They will vary in size from that of a large pin- 
head to a small or large lentil or a ten-cent-piece. The 
smaller ones are round or oval, while the larger ones are 
irregular in shape. In some places two or more larger 
ones may unite to form still larger, irregular, serpiginous 
patches. The lesions are often concealed by the long 
hair. 

By the coalescence of patches large ones up to the size 
of the palm of the hand may form, irregular in shape, 
polycyclic, with notches in the edges showing the remains 
of primitive patches; or band shape with single hairs 
or tufts of hair in the cicatricial tissue. Usually there 
are small and large patches, sharply defined, with an 



FOLLICULITIS DECALVANS 



331 



erythematous zone, in which will be hairs showing 
folliculitis, or some scaling. 



Fig. 41 




Pseudopelade. (Brocq.) 
Fig. 42 




Pseudopelade. (Broeq.) 



332 DISEASES OF THE SKIN 

The diseased scalp is thinned, atrophied, or depressed 
ordinarily,, but it may be smooth and soft, at times 
transparent resembling an onion skin. Exceptionally 
it is lardaceous and succulent. Sensation may be lost 
in the large patches especially. The hairs at the edge 
of the patches may be normal, or show some signs of 
inflammation about them. When the hair falls it has 
a pulpy, transparent sleeve about its root. All signs of 
inflammation cease with the falling of the hair. 

The course of the disease is very slow, excepting at the 
beginning, when it may be rapid. Its progress is usually 
marked by periods of quiescence and activity. It takes 
several years to involve a large part of the scalp and 
while it never causes complete alopecia, the alopecia is 
permanent. 

Etiology. — The disease occurs between the twentieth 
and fortieth years of life, most frequently in men with 
dark hair. It is probably parasitic, though no one has 
isolated a parasite in connection with it. 

Diagnosis. — The disease is differentiated from alopecia 
areata by the absence of exclamation-point hairs, and by 
the presence of many small atrophic patches of permanent 
baldness. Lupus erythematosus differs from it by being in 
sharply defined patches either with red closely adherent 
scales, or else white and depressed with a red border. 
The patch of lupus is completely bald while in alopecia 
cicatrisata there are often little tufts of hair in the patches. 
When favus has its characteristic crusts there is no diffi- 
culty in diagnosis. In old favus there are tufts of dry 
curly, wiry hair, which are not seen in pseudopelade. 
Favus also is a disease of early life, and its hairs are full 
of spores. Depilatiny folliculitis has inflamed follicles, 
and pustules about the hair. In cicatricial alopecia from 
impetigo the areas of baldness are very small and few in 
number. 

Depilating Folliculitis. — This is the acne decalvante of 
Lailler, and the folliculite epilante of Quinquad. 



FOLLICULITIS DECALVANS 



333 



Symptoms. — This disease is most common in the 
scalp but may occur also in the beard, axillae, and on the 
pubes. It begins as small pustules or papules pierced 
by hairs. The pustules dry into small crusts. The 
lesions at first are disseminated and discrete. Neighbor- 
ing follicles become affected. The hair falls from the 
pustules and permanent cicatrices are left. In this way 

Fig. 43 




Depilating folliculitis. 



eventually bald patches are formed. Usually the process 
has gone on for some time before it is discovered, and then 
there will be found a number of small patches from one- 
half inch to an inch or more in diameter, which are pale 
white, usually glistening, smooth and cicatricial with red 
points in them. About their edges and among the neigh- 
boring hairs there are red papules, pustules, and puncti- 



334 



DISEASES OF THE SKIN 



form miliary abscesses with hair in their centres. When 
a hair is plucked from a diseased follicle a red point is 
left. In this way the disease spreads. There may be 
tufts of sound hair in among the bald areas. The disease 
is slowly progressive. Pruritus is often marked. 



Fig. 44 




Depilating folliculitis. 



Etiology. — Brocq considers the staphylococcus aureus 
as the direct cause of the disease, and the predisposing 
factors the same as in sycosis. 

Diagnosis. — The disease must be diagnosed from 
alopecia areata, favus, lupus erythematosus, ringworm, 
and alopecia cicatrisata (which see). 

Prognosis. — There is no possibility of restoring the 
hair in either form of the disease. The baldness is per- 
manent. It is possible to check the advance of the 
disease in some cases. After a while it may reach a 
quiescent stage spontaneously. 

Treatment. — In either form the hair should be plucked 
from the diseased follicles, and a sulphur or mercury 



FORDYCE'S DISEASE OF THE LIPS 335 

ointment well rubbed into the scalp. We have seen the 
course of the disease apparently stopped by the daily 
use of: 

1$ — Ac. salicylici, gr. xv 1 

Sulphur, colloidal, 3.i 4 

Adepis lanse, 

Adepis anserini, aa p. e. ad 5J 32 

01. rosae geran., gtt. viij M. 

The scalp is to be washed once or twice a week, and the 
ointment applied after the hair is dry. 

Folliculitis, Depilating, of the Limbs. — This is a rare 
affection which is met with chiefly on the anterior 
and lower parts of the legs and on the thighs. It 
is symmetrical. It begins as red papules, from millet 
seed to pea size, pierced by a hair. This is soon sur- 
mounted by a pustule that dries into a crust. After 
some weeks the papule becomes absorbed, the hair falls, 
and a small pigmented cicatrix is left. The hair is per- 
manently lost, a punctiform cicatrix marking its former 
site. The disease occurs in patches surrounded by an 
irregular and ill-defined zone of folliculitis in process of 
development. It is chronic in its course, occurs usually 
in middle-aged men, and arises without known cause. 
Treatment has thus far been without effect. 

Fordyce's Disease of the Lips. — In 1896 J. A. Fordyce 1 
first called attention to this disease, which is probably not 
very rare, as a number of cases have been reported since 
then. It affects the mucous membranes of the lips in the 
form of patches made up of small, irregular, closely 
aggregated milium-like bodies of light-yellow color, 
located just beneath the mucous membrane. The same 
bodies are also scattered disseminately about the patches. 
Burning and itching, and a feeling of tension as if the 
lip were swollen, are complained of. Similar lesions 
occur on the inside of the cheeks along the line of the 
closed teeth. These are somewhat lighter in color, 

1 Jour. Cutan. and Gen.-Urin. Dis., 1896, xiv, 413. 



336 DISEASES OF THE SKIN 

more elevated and papillomatous. The milium-like 
bodies can be removed readily. They may be found in 
several members of the same family, and increase with 
age. They are atrophic sebaceous glands in the mucous 
membrane. Thus far no effective treatment has been 
found. 

Fragilitas Crinium. — See Atrophia pilorum propria. 
Frambesia. — See Yaws and Dermatitis papillaris capil- 
litii. 

Freckles. — See Lentigo. 

Frost-bite. — See Dermatitis calorica. 

Fungous Foot of India. — Synonyms: Madura foot; 
Mycetoma; Podelcoma; Ulcus grave; Tubercular dis- 
ease of the foot. 

This is a disease that is endemic in certain parts of 
India, but has been met with in this country. Though 
usually affecting the foot and leg, it is seen occasionally 
on the hands, shoulders, and scrotum. According to 
Crocker, there are three varieties, the pale, the black, 
and the red, the latter being very rare. It may begin 
with slight congestion of the affected part; or as a local 
induration, either superficial or deeply seated, of some 
part of the foot, which is firmer, larger, more diffused, 
and less painful than a boil. When this is opened, it 
discharges pus at first, later granules like poppy seeds, or 
mulberry-like masses are mingled with the discharge. Or 
it may begin as a blackish or bluish mottled discoloration 
like tattoo puncta. The progress of the disease is slow, 
but in the course of a few years the foot becomes swollen 
and distorted, the arch being broken, the toes being over- 
extended, and the sole convex from behind forward. It 
becomes dotted over with the raised orifices of sinuses 
extending deep down into the tissues, and giving vent 
to the above-described discharge. 

It is more common in males than in females, and in 
those who work barefoot, and is rare before puberty. 
Its origin is obscure, though it is supposed to be due to 



FURUNCULUS 



337 



a fungus, perhaps to more than one. It is said by Oppen- 
heim 1 that the pale variety is caused by an actinomy- 
cosis, and the black variety by an oidium or mold fungus. 
Surgical interference combined with the administration 
of iodide of potassium in large doses is the only hope 
for a cure. 

Fig. -45 




Mycetoma. 



Furunculus. — -Synonyms: (Ft.) Furoncle, Clou; (Ger.) 
Blutschwar; Furuncle or Boil. 

An acute circumscribed phlegmonous inflammation 
around a skin gland or hair follicle, characterized by one 
or more round, more or less acuminated, firm, painful 
formations, and usually terminating by necrosis and 
suppuration (Foster). 



1 Archiv f. Derm. u. Syph., 1904, lxxi, 209. 



22 



338 DISEASES OF THE SKIN 

Symptoms. — This is a common and familiar disease of 
the skin. Its most frequent locations are the back of 
the neck, face, forearms, buttocks, and legs, though it may 
occur anywhere. It begins as a small, round, red, pain- 
ful spot, which in two or three days enlarges to attain the 
size of a split pea or silver quarter- or half-dollar. It 
is now raised above the surface, hard, of a dark-red color 
at the centre, with the redness fading away into the sound 
skin, more or less pyramidal in shape, exquisitely tender 
to the touch, and with a most agonizing throbbing pain. 
Its centre soon becomes yellow, indicating the point at 
which suppuration has taken place, and where it will open. 
From the opening comes the "core," a greenish-gray or 
whitish pultaceous mass mixed with pus and blood. With 
the escape of this all the symptoms subside and the cavity 
fills up by granulation, leaving more or less of a scar. 
The course of the individual boil is from seven to ten or 
fifteen days. At times suppuration does not take place, 
but the mass undergoes resolution. This is the so-called 
"blind boil." Any boil may leave in the skin a thickened, 
indurated mass that slowly undergoes absorption. 

There may be but one boil or there may be dozens of 
them. They come out in crops of from two to half a 
dozen at a time. If very numerous, or of large size, 
they give rise to constitutional disturbance. They may 
continue to form for weeks, months, or even years, if 
left untreated. This is what is called furunculosis . 

Boils are always isolated. They may be confined to 
one locality or come out in a number of regions at the 
same time. There may be sympathetic enlargement of 
the neighboring lymphatic glands. If the disease is 
extensive, the patient presents a truly pitiable condition. 

If a boil starts from a sweat gland, it resembles that 
which originates in a sebaceous gland, except, according 
to Crocker, it has no mattery head and is somewhat 
less indurated. This form of boil is called hydradenitis by 
Verneuil and Bazin. It is of the size of a pea, and is most 
often met with in the axillae, about the anus and perineum, 



FURUNCULUS 339 

near the nipples, and may form anywhere where there 
are sweat glands, excepting on the soles of the feet. 

Boils may occur in the external auditory canal in 
conjunction with the disease elsewhere. They are exceed- 
ingly painful and produce deafness. One or both ears may 
be affected, but usually it is only one ear. They may set 
up inflammation of the entire canal and tympanum; one 
case of this sort has ended fatally. If the furuncle is situ- 
ated in the posterior wall of the canal, or a general in- 
flammation has been set up, considerable redness and tume- 
faction over the mastoid region may occur (Dr. A. Rupp 1 ). 

Etiology. — The cause of furuncles is the entrance 
into the skin of the staphylococcus pyogenes aureus et 
albus. Local infection produces crops of boils occurring 
in one region, and the doctrine of local infection finds 
further support in the results of treatment by antiseptics. 
It must be remembered that these micrococci are widely 
distributed, having been found in dish-water, in the super- 
ficial layers of decayed vegetable matter, in the swaddling 
clothes of healthy infants, in the dirt under the finger nails, 
and in numerous other places. Like other parasites, 
these require some peculiarity of soil for their growth, or 
at least an opportunity for gaining entrance to the gland- 
ular apparatus of the skin. The soil is afforded in lowered 
vitality of the skin, and thus we find boils in diabetes 
mellitus, after specific fevers, in anemia, lithemia, uremia, 
and septicemia; and as a complication of other skin dis- 
eases, such as eczema, prurigo, lichen tropicus, and 
scabies. In many, perhaps in most cases, no disorder of 
the general health can be discovered. The second con- 
dition is fulfilled by local injury to the skin, such as 
friction or pressure, or scratching. Boils are contagious, as 
well as auto-inoculable, and can be produced by inocula- 
tion of pure cultures of the micrococcus. The popular 
notion of their origin from too good living or from being 
run down is only another way of saying that they occur in 

1 Personally communicated. 



340 DISEASES OF THE SKIN 

individuals not in perfect health. Boils are said to affect 
males more often than females, and to occur especially 
between the twentieth and fortieth years of age. 

Pathology. — The inflammation begins in the corium 
and deeper tissues in or about the hair follicles or glands 
of the skin. "The mechanism of the process is supposed 
by some to be that the vessels around the gland or follicle 
become blocked, producing its death, and inflammation is 
then set up around the necrosed tissue to get rid of it by 
suppuration." (Crocker.) 

Diagnosis.— The disease is so common that there is no 
need for detailing the diagnosis. For the diagnosis from 
carbuncle, see under that word. 

Treatment. — In most cases there is no need of inter- 
nal treatment. If the patient is out of health in any way, 
we should endeavor to help him back to his normal con- 
dition. In furunculosis we should always bear in mind 
the probability of there being diabetes mellitus at the 
bottom of the mischief, seek for it, and do our best to 
cure the patient if we find evidence of it. There are 
many drugs recommended for the treatment of boils, 
apart from constitutional conditions. Of these, sulphide 
of calcium is one of the most popular, y 1 -^ of a grain being 
given every two or three hours, or a J to \ grain three 
or four times a day. It is of doubtful efficacy. Piffard 
speaks well of the compound syrup of the hypophos- 
phites, a dessertspoonful three times a day. Hardy 
recommends tar-water up to a quart a day. The sulphite 
or hyposulphite of sodium in 15 to 20 grain (1 to 1.33) 
doses three times a day is also well spoken of. Yeast 
is a homely but sometimes efficient remedy, either a J 
wineglassful being taken night and morning, or a like 
quantity in divided doses, or one of Fleischmann's yeast 
cakes being eaten during the day. Le Gendre, 1 believing 
that boils may arise from the absorption of products of 
imperfect digestion, advises the disinfection of the intes- 
tinal tract by the use of the following powder: 

1 Union med., 1888, xlv, 98. 



FURUNCULUS 341 

3— £-naphtol, 

Bismuth, salicylate 

Magnesia carb., aa gr. ivss 30 M. 

which is to be given every four hours. 

The most recent method of internal treatment is by 
vaccines. Engman says: Bacteriotherapy as frequently 
fails in the treatment of boils as it succeeds. Autogenous 
vaccines in such conditions should always be made. The 
dose varies widely, 50,000,000 should be the initial dose 
at four days' interval. The daily dose as practised by 
many ignores the negative phase and is the source of 
many failures. The stimulation of antibody formation 
must follow certain fixed chemical and physical laws, few 
of which are definitely known, but those known must be 
followed to obtain results. Hot packs and Bier's cups 
assist the lymph to the part. 

The local treatment of boils is important and efficient. 
They should not be poulticed, as, being due to a fungus, 
the heat and moisture only facilitate the growth of the 
same and the production of new boils. That new boils 
are apt to spring up about a poulticed boil is a common 
experience, and for this reason, if it is deemed advis- 
able to obtain the relief and comfort that a poultice 
undoubtedly gives, hot compresses of boric acid should 
be used. The best treatment for boils is the following: 
Around the sharpened end of a wooden toothpick is 
wound a small bit of absorbent cotton. This is dipped 
in carbolic acid solution, full strength, and bored into 
the cavity of the boil. The boil should not be squeezed. 
A 10 per cent, ointment of salicylic acid should be worn 
constantly over and about the boil. If the boil has not 
pointed a few drops of a 2 per cent, solution of carbolic 
acid may be injected into its base. Mercury may be used 
instead of carbolic acid, the boils being kept covered 
with emplastrum hydrarg, with a little hole cut in the 
plaster to correspond to the centre of each boil; or an 
ointment of the nitrate or red oxide may be used. Painting 
with iodin is also commended; as well as keeping them 



342 DISEASES OF THE SKIN' 

covered with a saturated solution of boric acid, or an 
8 or 10 per cent, plaster or ointment of salicylic acid. 
Hardaway speaks highly of Unna's carbolic acid and 
mercury mull plaster. Electrolysis to destroy the follicle 
is spoken of by the same authority. 

For some time after the boils are apparently cured it is 
well to bathe the affected region daily with a saturated 
solution of boric acid. 

Furuncles of the Ear.— My friend, Dr. A. Rupp, late 
aural surgeon to the New York Eye and Ear Infirmary, 
has kindly advised me on this head as follows: In the 
treatment of furuncles of the external auditory canal the 
first requisite is that the physician sees that which he is 
to treat. If the auditory canal be filled or unclean, it 
must be syringed out with a 2 to 5 per cent, solution of 
carbolic acid, followed by a solution of bicarbonate of 
soda as hot as can be comfortably borne. 

The canal is to be dried with absorbent cotton, and if 
the membrana tympani is intact filled with 

33 



1$ — Hydrarg. bichlor., gr. v 

Glycerini, 
Alcoholis, aa 5J aa 32 



M. 



which is to remain in some minutes, and then the excess 
is allowed to drain off. The canal is lightly closed with 
borated or salicylated absorbent cotton. Protargol, 5 
grains (0.32) to the ounce (32) of water, applied on pledgets 
of absorbent cotton and left in for an hour or two, gives 
good results. If the membrana tympani is deficient, the 
whole canal is to be filled with powdered boric acid and 
the orifice closed as before. In either cases the cotton 
is to be changed when soiled. When furuncles are at 
the inner end of the canal near the membrana tympani, 
a leech or two in front and a little above the tragus will 
afford much relief. It is unnecessary to incise the fur- 
uncles except where pus has formed and has no outlet. 

Prognosis. — In most cases boils are annoying, but not 
dangerous. Those about the face give the most trouble. 
Each boil runs its course in from one to two weeks. 



GANGOSA 



343 



How long new boils will continue to form it is impossible 
to say. If the treatment by carbolic acid is used, the 
disease is usually soon over. In furunculosis all will 
depend upon how soon we can get the patient into a 
better physical condition. 

Gangosa. — Synonyms: Rhinopharyngitis mutilans. 

Symptoms. — According to Mink and McLean 1 this 
disease begins as a tonsillitis or pharyngitis. A yellowish- 
gray membrane forms. It is elevated, thick, and tena- 

Fig. 46 




Gangosa. 

cious. In twenty-four hours ulceration takes place. 
The ulcer is punched out, has undermined edges and a 
deep uneven floor covered with a yellowish-white, offen- 
sively smelling discharge, with an inflammatory zone one- 
quarter of an inch wide about it. It rapidly increases 
in depth, perforates in seven days, then spreads slowly 
and steadily, emerges from the nose or oral cavity on to 

1 Jour. Cutan. Dis., 1907, xxv, 503. 



344 DISEASES OF THE SKIN 

the face, and after years causes great deformity by 
converting the skin into a cicatrix. It may last many 
years with periods of quiescence and activity, without 
affecting the general health of the patient. Less common 
is a fulminating form with rapid toxemia and death. 

Etiology.— The disease occurs in tropical countries, 
and is especially common in Guam and the Philippines. 
Most cases occur in the second and third decade of life. 
It is slightly more common in women. It rarely affects 
the white race. It is not hereditary. It is due to an 
undetermined infective agent. 

Diagnosis. — It differs from leprosy in its sudden 
onset, absence of bacilli, and by not affecting the health 
of the patient; and from syphilis by an absence of the 
history and symptoms of that disease, and by not yielding 
to its treatment. 

Treatment. — The authors found the application of 
tincture of iodin to be the best treatment, combined with 
antiseptics. Kern 1 has cured cases with mercury, using 
mixed doses. He found the Wassermann to be positive 
in many cases. 

Gangrene of the Skin. — See Dermatitis gangrenosa. 
German Measles. — See Rubeola. 

Geromorphisme Cutane is the name chosen by Drs. 
Souques and Charot 2 to designate an affection that pro- 
duced changes in the skin of a girl eleven years of age 
so that she looked like an old woman. The expression 
of the face suggested that due to facial paralysis. The 
skin hung in loose folds, and was flabby like the skin 
sometimes seen in very old people. Apart from loss of 
natural consistence and elasticity there was no change in 
the skin. If lifted up, twisted, or folded in any way, it 
returned very slowly to its normal position; and it was 
abnormally movable over the subcutaneous tissues, in 
these things suggesting that form of dermatolysis called 

1 U. S. Naval Med. Bui., 1913, p. 188. 

2 Nouvelle Iconographie de la Salpetriere. 



GRANULOMA ANNULARE 



345 



"elastic skin/' There were no changes in the hair, 
nails, or teeth. There was no assignable cause for the 
condition, which was preserved unaltered during an 
interval of ten years from the first to the last time that 
the doctor saw the case. 

Glanders. — See Equinia. 

Goose Flesh. — See Cutis anserina. 

Granuloma Annulare. — Synonyms: Ringed eruption; 
Lichen annularis; Sarcoid tumors; Eruption chronique 
circinee de la main. 

Fig. 47 




Granuloma annulare. (Little.) 

Symptoms. — The disease may begin suddenly, or 
slowly, as a smooth, whitish, bluish or purplish red, 
translucent nodule, which is made more visible by putting 
the skin on the stretch. It is deeply seated in the skin 
and has a firm or doughy feel. More nodules appear, 
and group themselves in a circle, crescent, or a festooned- 
shaped lesion. Or the original nodule may spread out 
into a ring by the disappearance of its centre. The 



346 DISEASES OF THE SKIN 

diameter of the ring is from a half-inch to two inches, 
and its border is a sixteenth of an inch broad and high. 
The centre of the ring may be of normal skin color, or 
pinkish, or show slight atrophy, but no scar is left on 
healing. Its course is very sluggish. It may last for 
seven or more years. It shows little tendency to spon- 
taneous recovery, but does disappear in course of time 
of itself. There are no subjective symptoms. The most 
common site of the disease is on the back of the hands, 
fingers, and wrists. It may occur anywhere on the body, 
though the scalp and face are rarely affected. There 
may be only one ring, or several; but the eruption is 
never profuse. 

Etiology. — Little is known of its cause. It begins 
most often in summer, and affects children and young 
people most usually. The youngest case reported was 
eighteen months, and the oldest was fifty-two years. 
It is perhaps predisposed to by a tuberculous family 
tendency. 

Pathology. — According to Graham Little 1 the chief 
changes in the skin are found in the zone where the 
corium and hypoderm meet. Here there is an accumula- 
tion of cells forming a microscopic nodule, the central 
part of which seems to be composed of dilated sweat 
coils. Similar groups of cells are found about the hair 
follicles and probably about the bloodvessels. Numerous 
rows of cells ascend from these to the surface of the skin 
apparently along the course of the sweat ducts, hair 
shafts, and bloodvessels. There are also numerous 
horizontal rows, and a scattered cell infiltration per- 
meating the connective tissue. The cells are of three 
kinds: (1) Large mononuclear cells; (2) Spindle-shaped, 
oblong, or pear-shaped cells, and (3) a few large, faintly 
stained "epithelioid" cells. 

Diagnosis.— The disease has such unique features 
that it is easily recognized. Its slow course, and the 

1 British Jour. Dermat., 1908, xx, 213. 



GRANULOMA PYOGENICUM 347 

absence of itching, damage to the skin, and subjective 
symptoms distinguish it from lichen planus annularis, 
and syphilis. 

Treatment. — The local application of resorcin, sali- 
cylic acid, or ichthyol is efficient. 

Granuloma Coccioides, also called Coccioidal Dermatitis, 
is a disease of which cases have been reported almost 
exclusively from California. It is unsettled whether it 
is a disease entity or a form of blastomycetic dermatitis. 
It is a general infection affecting the lungs, viscera, 
bones, and skin. In some cases the latter escapes entirely. 
Its cutaneous manifestations are various. There may 
be tumors, abscesses, or ulcerations. It may resemble 
blastomycosis, tuberculosis, syphilis, and even glanders. 
It spreads from the point of infection, if in the skin, 
by way of the lymphatics. It runs a chronic course and 
commonly ends fatally. 

It is caused by infection with a peculiar form of oidium, 
or mold fungus. Those who regard the disease as 
distinct from blastomycosis claim that it is a general 
infection instead of being most often in the skin; that 
the point of infection is most usually within the body and 
not in the skin; that its parasite shows no buds but 
multiplies by endosporulation; and that its cultures are 
not identical with those of the latter disease. Moreover 
it does not yield to treatment with iodid of potassium. 

It is almost uniformally fatal and thus far no treatment 
for it has been devised. 

Granuloma Fungoides. — See Mycosis fungoides. 

Granuloma Pyogenicum. — This is a pea- to nut-sized 
tumor consisting of granulation tissue. "Proud flesh" 
is of this nature. It may be sessile or pedunculated. 
It is seen about wounds, such as that caused by vaccina- 
tion. It is probable that there is some specific germ to 
cause the growth of these exuberant granulations. It 
sometimes takes the form of a raspberry. The application 



348 DISEASES OF THE SKIN 

of nitrate of silver, tincture of iodin, or some antiseptic 
powder to it will cause it to flatten down speedily. 

Granulosis Rubra Nasi is a disease of the nose of chil- 
dren. The cartilaginous part of the nose is more or less 
red, the redness not being sharply defined. It sometimes 
spreads to the cheeks and upper lip. Upon the red base 
are isolated, dark-red papules which may be very small 
and scarcely elevated, or pinhead size and prominent. 
They are pointed, non-confluent, and apparently located 
about the follicle mouths. They pale on pressure. Small 
vesicles or pustules appear that soon dry up. The nose 
is generally cold to the touch. There may be telangiec- 
tases. There is no scaling. Hyperidrosis of the nose or 
of the whole face is a constant factor. The disease 
grows better and worse, at times disappearing, but it does 
not change with the weather. Most of the cases occur 
in children from seven to sixteen years old who are not 
robust. Jadassohn's 1 patients were mostly boys. Brandle 2 
on the other hand has seen more in girls. It is very 
persistent, lasting for years, sometimes into adult life, 
though the disease tends to disappear at the time of 
puberty. Pathologically, it is a chronic inflammation 
about the mouth of the sweat ducts. Treatment is 
unavailing. Brandle advises using arrays. 

Grocer's Itch is eczema of the hand. 

Ground Itch, or Uncinarial Dermatitis, is a disease of the 
feet seen in some tropical countries where the hookworm 
exists, and is caused by its larva? getting into the skin 
of the feet. They give rise to an eczematous, very 
itcjiy eruption of macules which become papular and 
vesicular, and run together to form patches. Bullae 
sometimes are seen, and they and the vesicles soon 
rupture and leave a raw, red, swollen, crusted surface. 
Untreated lesions may appear elsewhere than on the 

1 Archiv Derm. u. Syph., 1901, lviii, 145. 

2 Dermat. Zeitschrift, 1911, xviii, 965. . 



HEMATIDROSIS 349 

feet, and ulceration may take place. Soaking the feet 
in boric acid solution, cleanliness, and the use of remedies 
such as used in eczema cure the disease. 

Guinea-worm Disease, Dracontiasis, or Dracunculus, is 
met with endemically in tropical climates. It is caused 
by the larvae of the guinea- worm, or filaria medinensis, 
being swallowed, and developing in the body. It is 
possible that the worm may gain access through a trau- 
matism. The female makes its way into the muscles, 
and within nine or twelve months gives rise to the symp- 
toms of the disease. The male probably dies and is 
passed out of the body. The symptoms of the disease 
are a small tumor under the skin that feels like a coil 
of soft string; the appearance of a pea to filbert-sized 
vesicle upon this when the animal is about to escape; 
tension, pain, and itching; in severe cases inflammation, 
purulent discharge, hectic fever, and perhaps delirium. 
The worm is either gradually wholly extruded after the 
vesicle breaks, or a new tumor forms after a part has 
escaped, and this after a time breaks and the rest of 
the worm comes away. There may be only one worm 
or a legion of them. They are located most often on the 
foot, but may be found anywhere. 

Treatment.: — The treatment of the disease is to 
remove the worm, which is done by winding it carefully 
around a stick when the head is protruded, giving a turn 
or two every day until the worm is extracted. Manson 
advises against this, and speaks of injecting into the 
tumors a 1 to 1000 solution of bichloride of mercury. 
This kills the worm, and it can then be removed. Tinc- 
ture of asafetida in doses of 1 or 2 drams (4 to 8) three 
times a day kills the worm before extraction. 

Hematidrosis, or Hemidrosis, is a rare disease of the 
sweat glands in which, on account of an effusion of blood 
into the coils and their ducts by diapedesis from the sur- 
rounding vascular plexus, blood is discharged upon the 
skin along with the sweat. The subjects are apt to be 



350 DISEASES OF THE SKIN 

hysterical young women, though the affection has been 
seen in newborn children. It is in some cases vicarious 
menstruation. The points of election are the face, ear, 
umbilicus, hands, and feet. Ephidrosis cruenta and 
bleeding stigmata are other names for the curious malady. 
The treatment should be directed to the condition of the 
individual. 

Hair, Discolorations of. — Hair sometimes falls out to 
grow in of a different color. The continuous hypodermic 
administration of pilocarpin has been followed by a 
change in color of the hair from light to dark. Green 
hair occurs in workers in copper; blue hair occurs in 
workers in cobalt and indigo. These colors can be 
removed by washing. Yellow hair is occasionally seen in 
icterus. Various chemicals bleach the hair, such as 
peroxide of hydrogen. Chrysarobin stains it purple; 
resorcin may stain it green. Bicarbonate of soda changes 
dark hair to a dirty brown. 

Hemisporosis, a disease caused by hemispora stellata, 
is described by de Beurmann and Gougerot. 1 It takes 
the form of either an edematous, non-fluctuating, livid 
swelling which develops slowly and runs a chronic course; 
or of gummatous tumors. Abscesses form, the pus of 
which contains the parasites. It is cured by the ad- 
ministration of iodide of potassium. 

Henoch's Disease. — See Purpura fulminans. 

Herpes. — An acute inflammatory disease of the skin 
characterized by an eruption of one or more groups of 
vesicles upon reddened bases. 

There are two main varieties of the disease: one occur- 
ring upon the face, herpes facialis, and one occurring 
upon the genitals, herpes progenitalis. 

Symptoms. — Herpes facialis, also called herpes febrilis, 
herpes labialis, hydroa febrilis, fever blister, or cold sore, 

1 Archiv Derm. u. Syph., 1910, ci, 297. 



HERPES 351 

usually occurs upon the lower part of the face, about the 
mouth (Fig. 48). There is commonly some slight dis- 
turbance of the general economy, not as part of the dis- 
ease, but as the cause of it. The patient first notices 
more or less marked burning, stinging, or itching in the 
part, and perhaps at the same time erythematous papules 
may form. After a few hours a number of pinhead- to 

Fig. 48 










JJ' ;: - 



Herpes febrillis. 



pea-sized, clear, fully distended vesicles will appear upon 
an erythematous base. Perhaps the herpetic patch may 
appear suddenly without antecedent erythema. There is 
usually not more than one or two patches of small size. 
There may be a score or more of them, and they may be 
of large size. The patches are always irregular in shape. 
There may be but two or three vesicles in a group, or 



352 DISEASES OF THE SKIN 

there may be a dozen of them. They do not tend to 
break down of themselves, but after a few days dry up 
into a crust which falls and leaves a red spot that soon 
disappears. Sometimes the vesicles may coalesce into 
bullae, the covers of which may fall and a superficial 
ulceration be left. The duration of the disease is about 
eight or ten days. The most common location is upon 
the upper lip, but it may be anywhere upon the face, 
and not uncommonly the groups develop bilaterally. The 
mucous membrane of the mouth may also be involved, 
but here, owing to the heat and moisture, the vesicles are 
seldom seen, as they break down and leave excoriated 
points. There is a strong tendency for the disease to 
recur with the recurrence of the exciting cause. In some 
cases it recurs at irregular intervals for months and with- 
out apparent cause. 

Herpes may occur on any part of the body and pre- 
sent the same symptoms as when it occurs on the face. 
Pflugbeil 1 says that a generalized herpetiform exanthem 
is seen with diphtheria, gonorrhea, malaria, and some 
septic infections. In the vesicles are found the parasites 
of the disease in which it occurs. 

Etiology. — It is still an undetermined question 
whether herpes facialis is a zoster or not. By most 
authorities it is considered to be an independent disease; 
by a few it is thought to be an incomplete zoster. It is 
known to occur with catarrhal inflammations of mucous 
membranes, such as a coryza, bronchitis, or pneumonia; 
with digestive derangement, as gastritis or enteritis; 
with various febrile diseases such as malaria or scarlatina; 
and it is very often seen in women as a herald of the 
menstrual epoch, occurring with great regularity for years. 
It arises sometimes on account of an injury to the terminal 
ends of the nerves, and, as such injuries are liable to 
occur in the tender mucous membrane of the lips, this 
may be an explanation of its frequency about the mouth. 

1 Dermat. Zeit., 1910, xvii, 307. 



HERPES 353 

Infection has been invoked by a few observers as a cause, 
but this is not proved. It is evidently a neurosis, and 
in some cases no cause for it can be found excepting 
nerve disturbance. Sometimes it occurs coincidently 
with herpes progenitalis or with zoster. 

Diagnosis. — It must be diagnosed from zoster and 
from vesicular eczema. From zoster it differs in not 
occurring in a series of groups scattered along the course 
of distribution of the trigeminus; and in frequently being 
bilateral. Generally speaking, there is more marked 
neuralgia in zoster, though in some cases this is wanting. 
From eczema it differs in the large size of its vesicles, in 
their showing no tendency to break down, in being less 
pruriginous, in running a regular course, and in rapidly 
recovering by the simple drying up of the vesicles. 

Treatment. — Left to itself the disease will speedily 
get well, and really requires no treatment beyond protec- 
tion with flexible collodion or any indifferent soothing 
lotion or ointment. We are often asked if we cannot 
prevent or abort the disease when due to the menstrual 
flux. Women well know that the application of spirits 
of camphor will sometimes do this. Hardaway recom- 
mends rubbing the parts with borax. One of the alco- 
holic solutions recommended by Leloir for this purpose in 
herpes progenitalis may be used, namely, either 2 per 
cent, resorcin; 1 per cent, thymol; 3 per cent, menthol, or 
2 per cent, tannin frequently applied. Stelwagon recom- 
mends painting with the tincture of benzoin, especially 
when the corner of the mouth is affected. Two or three 
coats are to be laid on two or three times a day. 

Herpes Progenitalis. — This has been called herpes pre- 
putialis, but as it occurs in women as well as men and 
on other places than the prepuce, the name is obviously 
incorrect. 

Symptoms. — The eruption is preceded and accompanied 
by burning and itching, and the vesicles occur in groups 
upon an erythematous base. If on the prepuce, that part 
is sometimes swollen. The vesicles are at first clear 



354 DISEASES OF THE SKIN 

with serous contents, and if on moist locations, as under 
the prepuce or about the mucous membranes of the 
female genitals, they soon break down and leave tiny 
excoriations. There may be but one or several patches of 
herpes. The disease runs a course of eight or ten days 
and gets well of itself, unless irritated under the mistaken 
idea of its being a soft sore, chancroid. 

According to Bergh, 1 who has made a careful study of 
the disease in women, the groups usually contain five to 
eight pinhead- to hemp-seed-sized vesicles, but may have 
twenty to thirty-five millet- to poppy-seed-sized vesicles. 
Around each group is a reddish areola. The vesicles are 
isolated, and seldom confluent. Itching is apt to precede 
their outbreak. There may also be slight tenderness or 
swelling of the neighboring glands. In both sexes the 
patches may be unilateral, bilateral, or median. In men 
it occurs most frequently on the inner surface of the 
prepuce, then on its outer surface, the sulcus, glans, 
sheath of the penis, and rarely in the meatus. In women, 
Bergh found it most often on the labia majora, then the 
labia minora, and genito-anal region; seldom on the clitoris 
or in the vestibule; very rarely on the cervix uteri. The 
disease has a tendency to relapse, in men with each coitus, 
in women with each menstrual period. It is common in 
women to have herpes of the face at the same time, and 
this has been noted in men. In women, herpes facialis 
may occur with one menstruation, and herpes progenitalis 
with another. 

Etiology. — The cause of the disease is congestion of 
the genital region. Thus in men it is frequently seen two 
or three days after each coitus; or accompanying a gonor- 
rhea or chancroid. A long prepuce seems to predispose 
to it. In women it comes in 80 per cent, of the cases 
with menstruation (Bergh), and in them it does not seem 
to have any marked relation to the sexual act. It is also 
seen in connection with pregnancy and the puerperal 

1 Monatshefte f. prakt. Dermat., 1890, x, 1. 



HERPES 355 

state, as well as in gout, constipation, and digestive 
disorders. It is a not infrequent disease. Greenough 1 
met with it in men in about 17 per cent, of all venereal 
cases in private practice. In women there are no statistics 
from private practice, and, indeed, it is in this country 
but rarely reported. Both Bergh and Unna, however, 
met with it very frequently in public prostitutes in 
St. Petersburg and Hamburg. 

Diagnosis. — The disease of itself is of little moment, 
but is of great consequence viewed from a diagnostic 
stand-point on account of its liability to be taken for 
chancroid or for the initial lesion of syphilis. This can 
hardly occur if the vesicles are seen, but when they are no 
longer present some difficulty may arise. From chancroid 
the superficial character of the lesions and their grouping 
point to herpes. In case of doubt the use of a simple 
dusting powder for a day or two will clear up the difficulty 
because chancroid will continue to enlarge while herpes 
will become well. Auto-inoculation will afford positive 
evidence. From the initial lesion of syphilis herpes differs 
in the absence of all induration of its base and in the 
inflammatory character of the lesions. By dark-stage 
illumination the spirochetal are readily demonstrated in 
chancre. Here again a short wait will clear up the 
diagnosis. 

Treatment. — Herpes progenitalis will usually promptly 
disappear by the use of a dusting powder of bismuth, or 
oxide of zinc and starch; or by covering it with a piece of 
lint soaked in an astringent solution, such as a weak 
lotion of liquor plumbi subacetatis. If suppuration has 
occurred on account of bad treatment, and the glands 
are enlarged or tender, the patient had best be put in 
bed. Circumcision has been recommended to prevent 
recurrences, but is of doubtful efficacy. It is well to have 
the patient to wash the parts daily and after coitus. 
Marriage and fidelity to the wife are good means of 
curing a relapsing herpes. Astringent washes are useful 

1 Arch. Dermat., 1881, vii, 1. 



356 DISEASES OF THE SKIN 

in both sexes. If the "habit" of herpes progenitalis, 
as it may be termed, has been formed, careful hygienic 
and general treatment may be necessary for a cure. 
Stelwagon advises the use of the galvanic current, the 
positive electrode placed over the lumbar region, and 
the negative one over the affected part, a current of 
J to 2 ma. being used. Leloir's directions, as given 
under Herpes facialis, may be tried for aborting the 
disease. 

Herpes Circinatus is either erythema iris or tricho- 
phytosis corporis. 

Herpes Circinatus Bullosus was the name given by Wilson 
to what has since been called herpes gestationis. 

Herpes Gestationis is regarded as being a dermatitis 
herpetiformis occurring during and provoked by preg- 
nancy. It is prone to relapse with each succeeding 
pregnancy; and slowly subsides after delivery. Apart 
from its etiological relation, it corresponds closely to 
dermatitis herpetiformis, which see. 

Herpes Tonsurans Maculosus. — See Pityriasis rosea. 
Herpes Zoster. — See Zoster. 

Herpetide. — This is a class of skin disease which de- 
pends upon what the French writers call the herpetic 
diathesis. The affections in this class are marked by 
long duration, obstinacy to treatment, tendency to 
relapse, and more or less pain and discomfort. Under 
it are included eczema, the lichens, psoriasis, and prurigo. 

Hidrocy stoma. — This disease was formerly regarded 
as a pompholyx of the face, but Robinson 1 has shown 
that it is a separate affection. 

Symptoms. — The eruption occurs upon the face in the 
form of a large number of discrete, disseminated, tense, 
clear, watery, boiled-sago-grain-like vesicles. In size they 
vary from that of a pinhead to that of a pea. In color 

1 Jour. Cutan. and Gen.-Urin. Dis., 1893, xi, 203. 



H1DR0CYSTGMA 



357 



tliey may be light yellow, of a bluish tint, or white. If 
pricked, a drop of clear acid fluid escapes. They are 
obtuse, round, or ovoid. If they are present in great 
numbers, they may crowd closely together, but do not 
coalesce. There is no sign of inflammation about them, 



Fig. 49 




Hidrocystoma. 



and no subjective symptoms arise from them, excepting, 
at times, a feeling of tension or smarting that is not pro- 
nounced. After lasting several weeks they dry up and 
disappear, while new ones appear. The disease is always 
most pronounced in hot weather, and may disappear 
entirely in winter. 



358 DISEASES OF THE SKIN 

The eruption is usually seen upon the lower part of the 
forehead, the orbital region, nose, cheeks, lips, and chin, 
that is, upon the middle regions of the face. 

Etiology. — The disease occurs most often in women, 
and especially in washerwomen. It occurs also in men. 
It is a disease of adult life, which is favored by warmth 
and moisture. As it occurs but rarely, and is an acquired 
disease there must be some yet undiscovered cause for it. 

Pathology. — The secreting portion of some of the 
sweat glands has an enlarged lumen from dilatation of the 
tube and contraction or compression of the epithelial cells 
against the basement membrane, the lumen being filled 
with liquid, and a granular material resembling that 
usually seen in normal glands, but in increased amount. 
With the exceptions of those thus affected, the excretory 
apparatus is normal (Robinson). 

Treatment. — As far as possible the patient must 
avoid everything that will cause sweating. The individual 
lesions must be punctured. Dusting powders after 
wiping the face with pure alcohol are helpful. 

Hirsuties. — See Hypertrichosis. 
Hives. — See Urticaria. 

Hydroa is practically dermatitis herpetiformis. It is 
an old term recently revived, and is of uncertain sig- 
nificance. By some it is used to designate eruptions that 
are midway between erythema multiforme and pem- 
phigus. 

Hydroa Estivale.— See Hydroa vacciniforme. 

Hydroa Vacciniforme. — Hutchinson, under the name of 
"Recurrent Summer Eruption," Unna, under the name 
of " Hydroa Puerorum," and Bazin, under the name at 
the head of this section, and others under the title of 
Hydroa Estivale, have described a bullous disease that 
occurs in early childhood and upon exposed parts, espe- 
cially the nose, cheeks, and ears. It may occur on 



HYDRO A VACCINIFORME 359 

covered parts and later in life. It usually occurs in 
summer, and then seems to be due to the heat of the sun. 
It may occur in winter, and be due to the action of high 
winds. It is a symmetrical disease. There may be some 
malaise preceding the eruption which begins as erythem- 
atous spots on which bullse form as such or as the result 
of the confluence of vesicles, and commonly both vesicles 
and bullae are present at the same time. The vesicles 
are prone to become depressed in the centre, dry into 
crusts, and resemble vaccine scars. When the crusts fall 
they leave pit-like, red scars, which afterward become 
white, and are permanent. Sometimes the disease does 
not go beyond the erythematous stage. Usually there is 
no itching, but pain or burning. A single attack lasts two 
or three weeks. The disease recurs from time to time, 
the relapses at times being so frequent as to render the 
disease almost continuous; and tends to cease altogether 
as puberty is reached. The disease is related clinically 
to both bullous erythema and dermatitis herpetiformis, 
though it differs from them in leaving scars. 

Hydroa puerorum of Unna, according to Stelwagon, 
shows no predilection to exposed parts, is uninfluenced 
by heat or cold, and does not leave scars. 

Etiology and Pathology. — Exposure to sun and 
wind seem to be the exciting cause, especially the former. 
It affects boys almost exclusively. Scholtz 1 has found 
albumin in the urine during the attacks which disappears 
when the eruption does. He finds that the skin of the 
affected individuals is no more susceptible to the violet, 
ultraviolet, and blue rays than that of others. He regards 
it as possible that some kind of systemic intoxication is 
responsible for the peculiar reaction of the skin. Bowen 
has shown that it is inflammatory in character. 

The treatment is not very satisfactory. The exposed 
parts should be protected as much as possible from the 
action of the wind and sun by means of veils or a cala- 

1 Archiv. Dermat. u. Syph., 1907, lxxxv, 95. 



360 DISEASES OF THE SKIN 

min lotion. If bullae form, they must be treated as in 
pemphigus. 

Hyperesthesia. — This is that condition of the skin in 
which pain is experienced on the slightest contact even 
of a current of air, in this differing from dermatalgia, in 
which the pain is spontaneous. When the sense of pain 
is exaggerated while the sense of touch is lessened, it is 
called Hyperalgesia. The hypersensitiveness may be for 
cold only, or for heat only, which is not so common. It 
is a neurotic disease, and is met with most commonly as a 
symptom of other diseases, such as non-tubercular leprosy, 
hydrophobia, and hysteria. Idiopathic cases are met with, 
though rarely. The hyperesthesia may be general or 
localized, unilateral or symmetrical. 

The treatment is in most cases that of the disease 
of which it is but a symptom, and belongs rather to the 
domain of the neurologist than to that of the derma- 
tologist. 

Hyperidrosis. — Synonyms: Ephidrosis; Idrosis; Suda- 
toria; Polyhidrosis; Excessive sweating. 

A functional disorder of the sweat glands characterized 
by an excessive flow of sweat. 

Symptoms. — Hyperidrosis may be general or localized: 
unilateral or symmetrical; in large or small amount. The 
cases of general sweating occur most often symptomatic- 
ally in the course of general diseases, such as phthisis, 
malaria, and rheumatism, and do not concern us now. 
Some cases occur idiopathically. Such patients are 
usually fat. The hyperidrosis may be constant or at 
intervals, being excited by the slightest irritation of the 
nervous system, or by muscular exertion. The outburst 
of the sweat is generally preceded by a prickling sensa- 
tion. It is often accompanied by prickly heat (lichen 
tropicus) . 

We are called upon as dermatologists to treat localized 
sweating more often than the just-described variety, and 
such cases occur most commonly upon the palms and 



HYPERIDROSIS 361 

soles, in the axillae, about the genitals, and on the face 
and scalp. The excessive flow of sweat may be constant; 
but it is usually paroxysmal, and often under the influ- 
ence of the emotions. It is usually more pronounced in 
warm than in cold weather. Fat people are more prone 
to it than are those who are thin: anemic and delicate 
people rather than .the robust. The affected part may 
be warm or cold; if the first, it is apt to be somewhat 
hyperemic. Occurring in places that are warm and 
covered, such as the feet, bromidrosis is a common 
accompaniment. The disease may last for years. 

Sweating palms usually feel cold and clammy. Some- 
times the amount of sweating is only enough to keep 
them more or less constantly moist; sometimes it is so 
abundant that the sweat drops from the hands and fingers, 
or even fills up the hollow of the upturned palm and runs 
over the edge. It spoils gloves, and interferes with many 
forms of work. Sweating soles are soon followed by 
tender feet, the epidermis becoming sodden, macerated, 
and removed. It interferes with walking. The edge of 
the foot just about the soles appears as a white or gray 
line or seam of sodden epidermis with a pinkish seam above 
it. The sodden appearance is also well-marked between 
the toes. Sweating in the axillae spoils the clothing, and 
is only rendered worse by the rubber dress-shields so 
commonly worn by Avomen. Eczema accompanies it 
not infrequently. In its paroxysmal form it is frequently 
encountered in patients stripped for examination in 
public. This form has been aptly named by the French 
the "military sweat," as it is seen so often in examining 
recruits for the army. Sweating about the genitals is 
often accompanied by intertrigo, which may also occur 
on other parts subject to hyperidrosis where folds of skin 
are in contact. Sweating of the face is most commonly 
encountered upon the forehead, nose, and eyelids, beads 
of sweat standing out upon them or running off in little 
rivulets. It is here that hemidrosis is most common. 



362 DISEASES OF THE SKIN 

Upon the scalp it has been observed that its occurrence 
is frequently followed by loss of hair. 

Unilateral sweating is occasionally met with. It may 
affect half of the forehead, face, or whole body. Upon 
the forehead and face this form of sweating may occur as 
an accompaniment of migraine and be limited to the 
painful region; it is in paraplegia that one-half of the 
body alone is affected. Kaposi 1 has reported one case of 
hyperidrosis affecting only the upper half of the body. 

Etiology. — The disease is probably due to a disturb- 
ance in the sphere of the sympathetic system. The 
slightest excitement, as that from drinking a cup of tea, 
or some passing emotion, may cause it in those predis- 
posed to it. It has followed lesions of the cerebrospinal 
nerves. It occurs in all classes and conditions of men, 
and in all ages and both sexes. Stel wagon has found 
local hyperidrosis most frequently between the ages of 
twenty and forty years. In some cases it is hereditary. 

Ill health seems to be the cause in many cases; it 
may be anemia; chlorosis; lithemia; hysteria; neuras- 
thenia; or general debility. Flat-foot is found in con- 
nection with some cases affecting the feet. In any case 
it is purely a functional disease of the sweat glands, 
they being structurally unchanged. 

The diagnosis is so evident that we need not stop to 
differentiate it systematically. 

Treatment. — The condition of the patient's health is 
to be carefully investigated, and tonics, mineral acids, 
nux vomica, or other medicine ordered according to the 
nature of the case. If there is no indication for this 
plan, or it does not succeed, recourse may be had to 
belladonna or atropin to the point of producing their full 
physiological effect; or pilocarpin, yo grain, three times 
a day; or agaricin in doses of ■§■ grain; or ergot \ a drachm 
of the fluidextract three times a day. Crocker has found 

1 Arch. f. Dermat. u. Syph., 1899, xlix, 321. 



HYPERIDROSIS 363 

a full teaspoonful of precipitated sulphur in milk twice 
a day the best remedy. If it loosens the bowels too much, 
he prescribes it as follows: 



1$ — Pulv. cretae co., 


5"j 




12 


Pulv. cinnam. co., ad 


3ij 




8 


Sulph. prsecip., 


5i 


ad 


32 


Sig. — A teaspoonful twice a day. 









M. 



The local treatment of sweating hands and armpits in 
many cases is as unsatisfactory as the constitutional treat- 
ment. There have been many plans proposed. Local 
faradization is one agent. Very hot water may be sponged 
on for a few minutes; belladonna ointment or liniment 
may be rubbed in; or we may use some astringent applica- 
tion, as of subnitrate of bismuth, tannin, alum, sulphate 
of zinc, borax, and the like, in alcohol, ointment, or 
powder. As a rule, ointments cannot be used on the 
hands and face. The most reliable lotion is probably a 
saturated solution of boric acid, or a 3 per cent, solution 
of salicylic acid. Kaposi speaks highly of the good effect 
of bathing the parts with a 5 per cent, solution of naphtol 
in alcohol, and keeping them powdered with 1 part of 
naphtol to ^fay of starch. PifTard recommends freshly 
prepared silicic hydrate, 1 part, in cold cream, 9 parts. 
Sulphate of qidnin, 5 per cent, in alcohol, may be tried. 
For sweating of the feet permanganate of potash in 1 per 
cent, strength may be used. Unna recommends ichthyol 
in 2.5 per cent, ointment, and the use of ichthyol soap. 
Formalin in 3 per cent, solution painted on three times 
a day has its advocates. P. Richter 1 advises sprinkling 
tartaric acid between the toes and in the stockings for 
sweating of the feet; and painting with a 10 per cent, 
solution of chromic acid every five days for sweating of 
the hands. Stelwagon recommends a 10 to 20 per cent. 
tannic acid ointment, or diachylon ointment spread on 
cloths and applied snugly to the feet after washing them 
with soap and water. At the end of twelve hours the 

1 Allg. Med. Centr. Zeit., 1897, lxvi, 927. 



364 DISEASES OF THE SKIN 

dressings are to be changed without washing, and so 
continued for ten to fourteen days. The skin usually 
exfoliates at the end of that time, and then the feet are 
to be washed and dressed with a dusting powder. For 
other methods see under Bromidrosis. The x-ray has 
proved useful in all forms of localized sweating, and may 
be used in obstinate cases. Pusey advises their use one 
to three times a week until the sweating is checked, care 
being taken to avoid producing erythema. If the trouble 
recurs this treatment is to be repeated. 

The prognosis is doubtful, many cases proving very 
rebellious to treatment. 

Hypertrichosis. — Synonyms: Hirsuties; Trichauxis; 
Polytrichia; Dasyma; Trichosis hirsuties; (Fr.) Poils 
accidentels; Superfluous hair. 

Symptoms. — Hypertrichosis is a growth of hair that is 
either abnormal in amount or occurs in places where, 
normally, only lanugo hairs are present. It may be 
general or partial, congenital or acquired. The general 
form is also congenital, but it is never universal, as no 
hair grows upon the palms and soles, the backs of the 
last phalanges of the fingers and toes, the inside of the 
labia majora, the prepuce, and glans penis. Subjects 
of this malady are usually born covered more or less 
thickly with hair, which may be light or dark in color. 
This continues growing longer, coarser, and darker until 
it reaches its full development. As a rule, the long hair 
covering the body is fine, resembling more the hair of the 
head than that of the beard, as is also the case with the 
hair on the face of these people. With this excessive 
growth of hair there is usually combined a deficiency of 
teeth, especially marked in the upper jaw. Subjects of 
this malady are called homines pilosi, and are met with 
in all quarters of the world. 

Of partial congenital hypertrichosis we have an immense 
number of examples. This condition is apt to be of the 
nature of nevus. The distinction between a localized 






HYPERTRICHOSIS 365 

hypertrichosis and a nevus is made mostly upon the color 
of the underlying skin. In the former case the skin is 
perfectty normal, while in the latter it is pigmented and 
may be otherwise altered. These localized and partial 
cases of hypertrichosis are most frequently met with in 
the sacral or lumbar region, and not infrequently are 
associated with spina bifida. 

Partial acquired hypertrichosis is more common than is 
the congenital variety, and takes the form either of an 
excessive growth of hair in regions where it is usually 
found, or of the development of hair in regions usually 
hairless or provided only with downy or lanugo hair, or 
of the development of pubertal hair at an early age. 

The following cases are instances of excessive growth 
and precocious development. Chowne 1 speaks of a boy, 
eight years of age, who had the whiskers of a man. Beigel 2 
has seen a six-year-old girl with pudenda like a twenty- 
year old woman, both in shape and hair. A case of 
excessive growth was met with by Leonard 3 in a man 
whose beard measured seven feet six and a half inches in 
length. Other instances of excessive length of beard are 
found in medical literature. 4 Many men have an excess 
of hair upon the chest and shoulders. Hair is generally 
better developed upon the forearm than upon the upper 
arm, and upon the legs than upon the thighs. As men 
grow old they are apt to have long hairs grow from the 
nose, nostrils, and the ears. These are instances of the 
growth of strong hair where normally only lanugo hairs 
are present. 

The growth of the beard in women is the form of 
hypertrichosis which concerns us most, as it is the defor- 
mity which we will be called upon to cure. As women 
grow old, especially after they have passed through the 
menopause, a slight moustache or a few straggling dark 
hairs on other parts of the face often appear. These 

1 Lancet, 1852, i, 421. 2 Virchow's Archiv, 1868, xliv, 418. 

3 The Hair, its Diseases and Treatment, Detroit, 1881. 

4 Jackson and McMnrtry, Diseases of the Hair and Scalp, Phila., 1912. 



366 DISEASES OF THE SKIN 

growths seldom annoy them much, as they are accepted 
as evidences of advancing years. The case is very differ- 
ent when a young woman is afflicted with a beard, and 
most of the patients who apply for relief from their facial 
hair are between twenty and thirty-five years old. In 





Fig. 


50 




J 


■, 












\ 1« 


.y 






4 


11 








!■" '.■ .,/ 






,m 



Hirsuties. 1 



them the hair generally begins to grow so as to be notice- 
able at about the eighteenth year of age. To get rid of 
the trouble the tweezers are first resorted to; then depil- 
atories are tried; sometimes burning is attempted, and 
as a final refuge a razor is used. All the time the hair 



By the courtesy of Dr. S. Dana Hubbard. 



// YPERTRICHOSIS 367 

grows coarser and more abundant. Some of these women 
shun company, keep themselves shut up all day, their 
health deteriorates, and, constantly brooding over their 
misfortune, they are prone to become hypochondriacal 
and melancholic. The amount of hair present in these 
cases varies. Perhaps the commonest growth is the 
moustache alone. In most of our cases the hair has grown 
thickest and coarsest under the chin and upon the front 
of the throat. It is rare, even in the best developed cases, 
to have much hair under the lower lip. Sometimes the 
growth is as complete, as heavy, and as coarse as is met 
with in men. The skin in many cases is coarse, muddy, 
greasy, and studded with acne. 

From time to time cases of transitory hypertrichosis 
have been reported. This has been noticed during the 
treatment of a fractured limb, the hair being much more 
prominent upon the part that has been kept quiet and 
warm. In some of these cases the increase is probably 
more apparent than real, the hair not having been rubbed 
off by friction. Likewise, after injury to nerves the hair 
sometimes becomes hypertrophied, only to fall out after 
recovery. Continued irritation of a part, as by blisters, 
may stimulate hair growth which may or may not be 
transitory. The most interesting of this group of cases 
is that comprising those of hirsuties occurring during 
pregnancy and disappearing after some months. Wilson 
reported a case of delayed appearance of menstruation in 
which hair grew upon the face. After the menstrual func- 
tion was established the hair ceased to grow and gradually 
disappeared. We have had a case in a woman with 
amenorrhea, in which the hair disappeared from the 
face on the return of menstruation. 

Etiology. — The cause of hypertrichosis is very obscure 
in some of its forms, while in other varieties we can more 
readily discover it. In general congenital hirsuties heredity 
plays an important part. But hereditary tendencies 
will not explain the first appearance of these congenital 
cases. Virchow endeavored to account for them upon 



oG8 DISEASES OF THE SKIN 

the theory of nervous influence, founded upon the fact 
that in the Kostroma people — a markedly hairy father 
and son — the lack of development of the teeth and jaws 
was in the same zone as the overdevelopment of the 
hair on the forehead, nose, cheek, and ears; these regions 
all being supplied by branches of the trigeminus or fifth 
cranial nerve. Unna's theory of congenital hypertrichosis 
is that it is due to a persistence of the fetal or primitive 
hair; the change of type between the primitive and 
permanent hair not taking place. 

The cause of acquired hirsuties is, in some cases, not 
far to seek. Heat and moisture will apparently increase 
the growth of hair, just as they favor the growth of 
vegetable life. Thus the hair has grown luxuriantly 
under the stimulation of poultices, and on the limbs 
when confined in a fracture box. To these factors must 
be added an increase of the flow of blood to the part. 
Increase of the flow of blood will stimulate hair growth 
independently of heat and moisture. At least Prentiss' 
case of hair growing more luxuriantly and coarser under 
the use of pilocarpin, which causes hyperemia of the 
skin, would seem to indicate this. Hypertrichosis fol- 
lowing injury to nerves is probably dependent upon vaso- 
motor disturbances. The growth of hair upon exposed 
parts, as upon the arms and chest of laboring men, 
sailors, and the like, is due to the local irritation of the 
sun and wind. 

Now we come to the more obscure cause of facial hirsu- 
ties in women. To account for this, numerous hypotheses 
have been formed. Probably the one most generally 
accepted is that it is in some way connected with de- 
rangement of the uterus and appendages. Because in 
some bearded women there has been some evident 
derangement of the sexual organs, it has been affirmed 
that some similar derangement is present in all. This is 
on a par with the too loosely accepted idea that the too 
free use of alcohol is the only cause of rosacea. In the 
cases I have met with, the majority were as free from 



H YPERTRICHOSIS 369 

uterine trouble as the rest of their sex. While it is true 
that some of these women are of masculine build, and 
have a masculine voice, most of them do not exhibit 
these characteristics. In some cases, however, there 
does seem to be some relation between the reproductive 
organs and the growth of the beard. Heredity is well 
marked in the majority of cases. It is improbable that 
attempts at destroying the fine hair cause the develop- 
ment of the coarse hair. It is more likely that they 
only strengthen its growth. Women are prone to trace 
the appearance of hair on the face to the use of vaselin, 
cold cream, and the like. There is no scientific foundation 
for this. 

An interesting study of the relation between hirsuties 
in women and insanity was made by Hamilton. 1 He 
regards hair growth on the face in women as the in- 
evitable result of the overactive and continuous exercise 
of the uterine and ovarian functions. He believes it to be 
of neuropathic origin, connected with disorders of the fifth 
cranial nerve; and that when it occurs upon the face of 
an insane person it is indicative of an unfavorable form 
of insanity, especially if the subject has not reached mid- 
dle life. E. Dupre and Duflos 2 found among 1000 sane 
women 230 with fine hair on the face, 40 with a medium 
growth, and 10 with a heavy growth. Among 1000 
insane women they found 441 with a slight or medium 
growth of hair and 56 with a heavy growth. They also 
found evidences of neuropathic tendencies and mental 
derangements in the antecedents of many non-insane 
women with hirsuties. 

We may sum up the evidence on the etiology of facial 
hirsuties in this way: While at times there appears to be 
a relation between the uterine, or, more properly, the 
menstrual function, and the growth of hair on the face, 
shown by a decrease or deficiency of the first, and an 
increase of the second, still in the majority of cases no 

1 Med. Rec, 1881, xix, 281. 

2 Annal derm, et syph., 1902, 111 ct seq. 
24 



370 DISEASES OF THE SKIN 

such relation is discoverable, and it must be viewed as a 
deformity, or a freak of Nature, or as a matter of inheri- 
tance. 

Treatment. — For general hypertrichosis we can prac- 
tically do nothing. This, not because we cannot destroy 
hair so that it will not grow again, but because of the 
great amount of time it would take to destroy it. 

The only form of hirsuties which urgently calls for 
relief is that occurring upon the face of women. In 
1875 Dr. Michel, of St. Louis, devised the method of 
removing the hairs in trichiasis by means of electrolysis, 
which was taken up by Dr. Hardaway, of the same city, 
for the removal of superfluous hair. The question is 
often asked, "Is the removal, by this method, per- 
manent?" This question may be answered, "It is, 
without a shadow of a doubt." The object being to 
destroy the papilla, and that being very small and often 
placed at an unexpected angle to the surface of the skin, 
it is not possible always to accomplish this at the first 
attempt; but with patience and the necessary skill it 
will finally be permanently destroyed. At times, after 
the dark, coarse hairs have been removed, there will be 
found a number of finer and lighter hairs. This appear- 
ance is due partly to the uncovering of these hairs, and 
partly to lanugo hairs becoming stronger by natural 
development. In most cases, with proper care and the 
use of a fine needle, the amount of scarring will be very 
slight, amounting to nothing more than fine punctate 
cicatricial spots. In some peculiarly irritable skins it is 
very difficult to prevent the formation of plainly visible 
scars. The upper lip is also prone to scarring. If the 
proper conditions are not observed, the operator must 
expect to produce a good deal of disfigurement. 

The amount of pain experienced by the patient will 
vary greatly. Certain parts of the face are far more 
sensitive than others. On the whole, the pain does not 
amount to much. After a time the skin seems to become 
tolerant of the action of the current and the patient no 



H YPER T RICH OS IS 371 

longer complains. Hyperpigmentation may be produced 
by the operation. This is a very rare complication, and 
is mentioned only by way of warning. 

The instruments needed for the operation are a good 
twenty-cell zinc-carbon (galvanic) battery, or a rheo- 
stat connected with the street current, a sponge elec- 
trode, a proper needle-holder, a fine needle, a pair of 
epilating forceps, and, if the operator's eyes are not good, 
a lens of low power. Any sponge electrode will answer. 
There are various patterns of needle-holders, any one of 
which may be used. It should be long enough to be held 
with ease, and not too long to be readily manipulated. 
The most essential instrument is the needle. Hardaway 
recommends a needle made of iridium and platinum. He 
claims that it will follow the direction of the hair 
follicle, and more surely hit the papilla than a steel 
needle. We have had most satisfactory results with a 
jeweler's instrument called a " steel broach." These 
come in many grades; those known as Nos. 5 and 7 are 
serviceable ones. A lens is generally not needed. Dr. 
Piffard invented a needle-holder with lens attachment, 
which he has found useful. If one's eyesight is not good, 
he had best wear spectacles furnished with large magni- 
fying lenses. A galvanometer is not essential, but very 
desirable. 

A good light is necessary for the operation, and a 
cloudy day is a bad one for working. An operating-, 
reclining-, or dentist's chair, especially the last, is a com- 
fort, and the patient should be so placed that the part to 
be operated on is on a level with the operator's eye. 

The operation is done in the following manner: The 
patient, being in position, is to be given the sponge 
electrode attached to the positive pole of the bat- 
tery, and told to hold it in one hand. The hair to be 
extracted is then seized with the forceps, and put 
slightly on the stretch in the direction in which it nat- 
urally grows. The needle, attached to the negative pole, 
is then inserted parallel with the hair and into the 



372 DISEASES OF THE SKIN 

follicle. One soon learns to know whether the follicle 
is entered or not by the sense of touch. When the 
follicle is entered the needle glides along smoothly; 
when it is not entered a sense of resistance is communi- 
cated to the fingers as the skin is punctured. The depth 
to which the needle is to be thrust will vary with the 
case. Roughly speaking, it is from T V to T \ of an 
inch. The needle being inserted, the patient is told to 
place the palm of the disengaged hand over the sponge 
electrode. In a few moments there will be frothing about 
the needle, and in from half a minute to a minute or 
more the hair will come away upon the very slightest 
traction. The hand is to be removed from the sponge 
before the needle is withdrawn from the follicle. The 
hair must not be pulled on with any force, for the ease 
with which it leaves the follicle is evidence of the com- 
pleteness of the operation. The hairs must not be ex- 
tracted in close proximity, because the inflammatory 
action thus set up will lead to more or less deep ulceration 
and subsequent prominent scars. It is best to extract 
only the coarser hair, and to leave the lanugo hairs alone. 
The strength of the current to be used will depend upon 
the quality of the patient's skin and the recentness of the 
filling of the battery. Six cells are the fewest I have 
used, and fifteen the greatest number — more exactly, a 
current strength of 1 to 2 ma. 

Immediately after operating, the part worked on should 
be bathed with pure alcohol. The patient should be 
directed to bathe the face in hoi water and to anoint 
it with cold cream several times during the day following 
the operation. 

T. Bloebaum 1 advocates the use of galvanocaustic 
needles as superior to electrolysis for the destruction of 
hair. A platino-iridium needle is used by him, which 
is thrust while glowing 2 or 3 times into the follicle, and 
thus he destroys one hundred hairs in fifteen minutes. 

1 Deutsche med. Zeit., 1897, xviii, 609. 



H YPER TRW HOSTS 373 

He claims for his method not only greater celerity, but 
also less scarring and pain. The microbrenner of Unna 
has its advocates. Kromayer 1 recommends the use of 
specially constructed cylindrical knives from 0.1 to 2 mm. 
diameter, which are driven into the skin to the depth 
of 1| mm., and at once withdrawn. The hair comes 
away with the knife, or can be readily plucked out. He 
claims that his method does not leave scars. 

Of late, the x-rays have been used to destro3 T hair, and 
apparently successfully. The operation has to be often 
repeated, sometimes as many as 40 to 100 times. Short 
and mild exposures should be given, so as not to cause 
more than a passing erythema. They should be stopped 
as soon as the hair falls or an erythema occurs. After 
waiting six weeks a second, shorter, course of exposures 
should be made. There is always danger of dreadful 
scarring, and the production of lasting pigmentation and 
wrinkling of the skin with many telangiectases from 
their use, but improvement in technique is constantly 
lessening these dangers. In from one-third to one-half 
of the cases a successful result has been had. It is to 
be recommended only in very bad cases, where the 
patient prefers the wrinkled skin to the hair. 

The hair may be temporarily removed by pulling or 
shaving, or the use of depilatories. Of the latter, sulphide 
of barium 2 drachms (8), oxide of zinc and starch, each 
3 drachms (12), maybe used. The powder is to be mixed 
with water to the consistence of a paste, which is spread 
on the part for ten to fifteen minutes or until a certain 
amount of warmth is felt. It is then to be washed off 
and a soothing ointment applied. Any of these proced- 
ures makes the hair grow coarser. Sabouraud 2 says that 
if an ointment composed of: 



I^ — Thalii acetat., gr. v 

Zinci oxidi, £T. xxxvij 2 

Vaselin., 3v 20 
Lanolin., 

Aquae rosae, aa 3iss 5 



M. 
Deutsch. med. Woch., 1905, xxxi, 179. 2 La Clinique, 1912, p. 102. 



374 



DISEASES OF THE SKIN 



is applied every night to lanugo hairs it will destroy 
them in eighteen months. Peroxide of hydrogen may be 
advised to bleach dark hair and thus render it less con- 
spicuous. 

Fig. 51 




Hyponomoderma. (After Van Harlingen.) 

Hyponomoderma, or creeping eruption, is a disease of the 
skin due to its invasion by the larva migrans of gastro- 
philus. In this country it is very rare, but in Russia and 
Arabia it is said to be common. It is recognized as an 
irregular, tortuous, narrow, raised red line from one- 
sixth to one-eighth of an inch wide, the advancing end 
of which is club-shaped. It will be noted that the line 
extends over the surface of the skin at the rate of about 



ICHTHYOSIS 375 

one inch a day. The beginning of the track fades after a 
few days. There is no definite course of the disease. 
Crocker records a case which had continued extending for 
two and a quarter years. There may be some pruritus, 
especially when it occurs on the palms and soles, and 
the skin may be scratched. Any part of the body may be 
affected. Women are said to be more often affected than 
men in Russia. 

The larva is scarcely 1 mm. long, broadest in the 
middle, and bifurcated posteriorly. It is marked by 
numerous black plates, and has hook-like spines ar- 
ranged in nine rings about the body. About the mouth 
are a number of large and small prickles placed thickly 
in rows, from which protrude two small mouth-hooks. 
They live normally in the horse's stomach. It is prob- 
ably the eggs that are deposited on the skin of humans 
(Boas 1 ). 

The treatment is by excision of the dark end of the 
track. Stelwagon cured one case by cataphoresis with a 
solution of 2 grains to the ounce of bichloride of mer- 
cury to an inch and a half area about the advancing end, 
and nitric acid to the suspected site of the parasite. 
Hut chins 2 cured his case by injecting twoi or three drops 
of chloroform for one-quarter of an inch in the line of 
advancement, and covering it with zinc oxide plaster. 

Ichthyosis. — Synonyms: Xeroderma; Xeroderma ich- 
thyoides; Ichthyosis vera seu congenita; Sauriasis; 
(Fr.) Ichthyose; (Ger.) Fischschuppenausschlag; Fish- 
skin disease. 

Ichthyosis is a congenital, general or partial, chronic 
disease of the skin, characterized by dryness, harshness, 
and scaling of the skin, and sometimes by the develop- 
ment of warty looking growths. 

Symptoms. — Though the disease is congenital, it usually 
does not show itself until after the second month, and 



1 Monatshefte f. prakt. Dermat., 1907, xliv, 505. 

2 Jour. Cutan. Dis., 1909, xvi, 521. 



376 DISEASES OF THE SKIN 

sometimes not until the second year. There are four 
varieties of the disease, namely, xeroderma, ichthyosis 
simplex, ichthyosis hystrix, and ichthyosis congenita. 

Xeroderma is the mildest grade of the disease. The 
skin is dry, harsh, slightly scaly, grayish or dirty-look- 
ing, and its natural lines are more pronounced than usual. 
Upon the extensor surfaces of the limbs it is particularly 
marked, and here too it is accompanied by keratosis 
pilaris. It is most annoying to young women who want 
to wear short-sleeved dresses. It is doubtless far more 
common than statistics show, as it very often is slight 
in amount. 

Ichthyosis Simplex. — This is a more severe grade of the 
disease in which the skin is dry, harsh, and scaly, and 
divided off into small diamond-shaped or polygonal 
figures (Fig. 52). While the whole cutaneous surface 
may be involved, the disease is usually most pronounced 
upon the extensor surfaces of the legs and arms. The 
face, scalp, palms, and soles are often spared. The skin 
about the extensor surfaces of the elbows and knees is 
generally thrown into well-marked folds, while the flexor 
surfaces of the same joints are unaffected, the skin in 
these situations being soft and natural. While upon the 
extremities the disease is well developed, upon the trunk 
it may assume more of the xerodermatous form. When 
the face and scalp are affected they are simply very scaly, 
while on the palms and soles we have accentuation of the 
normal lines. In a typical case the skin, especially of the 
extremities, will be grayish, greenish, or blackish green 
in color, dry, and the little polygonal plates will be 
attached at their centres and turned up slightly at their 
edges, so that they appear depressed in the centres. The 
amount of loose scaling is sometimes abundant, but 
usually moderate in amount. The hair, if the scalp is 
involved, is dry. The nails are often pitted. Ectropion 
may result in those rare cases in which the disease affects 
the face severely. Itching is often complained of, and 
eczema may complicate matters. There are a marked 



ICHTHYOSIS 377 

absence of perspiration and lessened sebaceous secretion; 
and the patients are sensitive to cold,. The disease is 
usually worse in cold weather. 




Ichthyosis. 1 



Ichthyosis hystrix is a very rare form of ichthyosis, 
and occurs in the form of patches of warty, dark-green, 
papillary projections markedly raised above the skin, or of 
small papillary growths with horny caps. The skin feels 
rough and harsh. It may cover wide areas of the body, 
but does not involve the whole surface. The same name 
has been applied to an entirely different disease that is 
described under Papilloma lineare, to which the reader 
is referred. 

1 Courtesy of Dr. Fox. 



378 DISEASES OF THE SKIN 

Ichthyosis congenita is the most rare form of the dis- 
ease. It is also called Keratoma follicularis, Keratosis 
diffusa seu epidermica seii intra-uterina, and the " Har- 
lequin fetus." It is considered by some to be a general 
seborrhea. It is present at birth, the skin being covered 
with fatty epidermic plates cracked in all directions and 
arranged transversely to the axis of the body. The 
fissures may extend into the corium. The eyes are held 
partly open, or there may be ectropion; the lips cannot 
be moved; and the feet are contracted and deformed. 
The color is yellowish white or grayish. The scrotum 
and penis may not be involved. The infants are either 
born dead or survive birth but a short time, though 
S. Sherwell has reported one case that was living at five 
months of age. 

There are also cases of ichthyosis intra-uterina in which, 
after the removal of the vernix caseosa, the skin looks 
red, glazed, and dry, and soon assumes the characteristics 
of ichthyosis simplex. 

With the exception of ichthyosis congenita, the dis- 
ease does not show itself until some months after birth, 
but by the second year it has made its appearance. 
As a rule, it increases in severity as the patient grows 
older, until adult age, when it usually remains stationary 
or perhaps improves a little. It is a chronic disease and 
shows no tendency to get well. It does not seem to 
affect the patient's health, and it should be regarded 
rather as a deformity than a disease. Occasionally 
mental weakness and other congenital defects have been 
noticed. 

Etiology. — We know of no cause for the disease 
beyond heredity, which may be direct, skip a generation, 
or be through a lateral branch. Many cases occur without 
manifest heredity. It has been ascribed to consanguinity 
of the parents. It attacks both sexes about equally. It 
shows a tendency to occur only in one sex in certain 
families, while in other families both sexes are equally 
affected. It is a congenital defect in the development of 



ICHTHYOSIS 379 

the skin with a disturbance of the functions of the 
perspiratory and sebaceous glands. There are said to be 
cases of the disease that are not hereditary, but due to 
well-marked nerve disturbances, greatly reduced nutrition, 
and the drinking of ava, a fermented liquor in use in the 
Hawaiian Islands. 

Pathology. — The epidermis undergoes a peculiar 
cornification. Horny cells are formed directly from the 
rete without the intervention of a granular layer. The 
horny cells are homogeneous and apparently without 
nuclei. The thickness of the epidermis is due in part to 
the fact that the corneous cells are not shed as rapidly as 
in normal conditions. The sweat and sebaceous glands 
are constantly atrophied, or the latter may be entirely 
wanting. The panniculus adiposa is deficient, the elastic 
tissue unaltered, and the erectores pilorum hypertrophied. 

Diagnosis. — The disease is so unique that if its char- 
acteristics are remembered there can be no difficulty in 
diagnosis. There is no other disease commencing in 
infancy that at all corresponds to ichthyosis simplex. 
Xeroderma may resemble a mild grade of squamous 
eczema, but has not its history. Sometimes we meet 
with a dry skin that is not ichthyosis, but is only a 
passing state and has not existed from infancy. Ichthy- 
osis congenita differs from seborrhea in its crust not being 
removable by soaking in oil and by proving fatal. 

Treatment. — The treatment is largely palliative. 
The free use of Russian baths or of prolonged warm 
baths, simple or with soda, and washing with soap, 
followed by inunctions of vaselin, lanolin, or oil, such as 
cocoa-butter, will keep the skin supple. Unna 1 reports 
several cures from the use of Eucerin after bathing with 
salicylic acid soap. Kaposi recommends a 5 per cent. 
naphtol ointment, or a 2 per cent, solution in spirit us 
saponis, viridis, or cod-liver oil, in conjunction with 
naphtol soap. Andeer 2 recommends a 3 to 20 per cent. 

1 Monatshefte f. prakt. Dermat., 1909, xlviii, 261. 

2 Ibid., 1884, iii, 365. 



380 DISEASES OF THE SKIN 

ointment of resorcin well rubbed in, and covered with a 
bandage, and claims a cure in eight days. The daily 
application of a lotion composed of \ an ounce (16) to 
1 ounce (32) of glycerin in a pint (500) of rose-water or 
of lime-water is one of the simplest and best methods of 
treatment. Whatever is used must be persisted in. 

M. Bockhart 1 reports one apparent cure by giving a 
daily morning bath with soap and water, followed by an 
inunction of a 5 per cent, sulphur ointment. The oint- 
ment was used also at noon and at night. Internally, cod- 
liver oil was given. Twice a year for six weeks salt baths 
were substituted for the soap-and-water baths. After 
three years of continuous treatment a pause was had and 
there was no return for three months. After nine years' 
treatment, with pauses in between, the patient was well, 
and remained so up to the time of writing, after six years. 

Besnier recommends, as adjuvants to the local treat- 
ment, regular gymnastic exercise and the internal admin- 
istration of cod-liver oil. Thyroid extract has been used 
with benefit in some cases. It should never be used 
unless the patient can be watched by the physician, as 
it is a dangerous remedy. The administration of jabo- 
randi by the mouth or pilocarpin hypodermically will 
soften the skin, but in a deformity of the skin that 
cannot be removed its use is inadvisable. 

Axmann 2 reports a cure by the use of the Schott 
Uviol lamp. After nine sittings of ten minutes each the 
skin was smooth. After a pause of four weeks, nine 
more sittings were given. After thirty-five sittings with 
from eight to fourteen day pauses, the disease was cured. 

D. H. Stewart 3 effected a .permanent cure of one 
case by irrigation of the colon with 5 gallons of water at 
a temperature of 120° F., containing 4 tablespoonsful of 
table salt to the gallon. This was given one day, and 
on the next a pill of calomel and hyoscyamus was ad- 

1 Monatshefte f. prakt. Dermat., 1901, xxxiii, 616. 

2 Dermat. Zeitschrift, 1907, xiv, 109. 

3 Jour. Cutan. Dis., 1905, xxiii, 52. 



IMPETIGO SIMPLEX 381 

ministered. This alternating treatment was continued for 
four weeks, when the skin became smooth, and so con- 
tinued for more than two years. 

Pkognosis. — The prognosis is good as to life, bad as to 
cure. Thus far it has proved practically incurable. All 
one can hope to accomplish is to render the patient com- 
fortable and fit to mingle with his kind by repeated 
courses of treatment. Ichthyosis congenita is fatal in a 
few days, if the child is not born dead, as is usually the 
case. 

Impetigo Simplex. — Our own writers largely follow 
Duhring in their description of this disease, and as soon 
as they vary from his description, it seems to us that, 
instead of simple impetigo, they describe the contagious 
form. . According to Duhring, the appearance of the dis- 
ease may or may not be preceded by loss of appetite, 
constipation, or malaise. The eruption consists of one 
to a dozen or more pustules that are pustules from the 
beginning. They are split pea to finger nail in size, 
rounded, and raised above the surface of the skin. They 
have thick walls, a more or less marked areola, little 
surrounding infiltration, and no central depression. 
Their color is yellowish or whitish. They manifest no 
disposition to rupture, are discrete and disseminated, 
and do not incline to coalesce. While they may occur 
anywhere, they are seated by preference on the face, 
hands, feet, and lower extremities. Itching and burning 
are absent, as a rule. The course of the disease is acute, 
its duration being several weeks. The pustules gradually 
undergo absorption and dry into a crust, or they may be 
ruptured by external injury. The crust when it falls 
leaves a reddish base without pigmentation or scar. 
The disease is not contagious, and occurs mostly in 
children. 

Such is the disease as described by Duhring. It will 
be seen by reading the section on impetigo contagiosa 
that it bears a strong resemblance to that disease. He 



382 DISEASES OF THE SKIN 

differentiates it from impetigo contagiosa on account of 
its being pustular and not vesicopustular from the start, 
its deeper seat, and its being raised and not umbili- 
cated. 

Impetigo of Bockhardt. — The best description of this 
form of impetigo is by Sabouraud. 1 He described it as 
occurring primarily on hairy regions, usually the scalp, 
as an eruption of pustules pierced by hairs. They are 
confluent or disseminated. They are yellowish green, 
rounded, umbilicated or accuminated, and vary from 
millet to pea size. There is an areola about the young 
pustules which diminishes with their age. They are not 
readily broken. They reach full development in three 
to five days, the crust falling in a week. A folliculitis 
is often left, or a furuncle or abscess follows. There is 
sometimes a dermatitis of the scalp of severe grade, 
and the glands of the neck are often swollen. Suc- 
cessive crops of pustules are frequent, thus prolonging 
the course of the disease. The disease may spread from 
the scalp to the face, neck, back, thighs, and buttocks. 
It is due to infection with the staphylococcus aureus, 
and is regarded by Sabouraud as being distinct from 
impetigo contagiosa, though often complicated by it. 
His view is not accepted by all. Crocker regarded it as 
simply a form of contagious impetigo. 

Impetigo Contagiosa. — Synonyms: Porrigo contagiosa; 
Impetigo parasitica seu streptogenes. 

An acute inflammatory, contagious disease, occurring 
especially on the face, hands, and exposed parts, and char- 
acterized by the appearance of vesicopustules and bullae. 

Symptoms. — By Tilbury Fox, who first described the 
disease, and others who followed him, its onset is said to 
be marked by slight febrile disturbances. These are very 
slight, and we have not satisfied ourselves as to their 
occurrence in the many cases that we have seen, except 
incidentally as part of some digestive disorder that may 

1 Ann. de derm, et de syph., 1900, i,62 and 427. 






IMPETIGO CONTAGIOSA 



383 



be present. The eruption consists of flat vesicopustules 
that come out in crops. They are of various sizes, from 
a pea to a finger-nail. They are at first surrounded in 
well-marked cases with a red halo, which soon fades. 
They tend to increase slowly in size, and sometimes 
assume an annular shape. They are not fully distended, 
but flaccid, and not infrequently upon the hands, espe- 




Impetigo contagiosa. 1 

cially in children, they bear a strong resemblance to a 
burn of the second degree. If the covers of the vesicles 
or small bullae are not disturbed, their contents in a few 
days will dry up, and the vesicopustule will change into 
a straw-yellow granular crust, which is placed super- 
ficially upon the skin with its edge somewhat detached, 

1 G. H. Fox: The Skin Diseases of Children, New York, 1897. 



384 



DISEASES OF THE SKIN 



and, it may be, turned up — in fact, it looks "stuck on." 
When the crust is removed or falls of itself, there is 
exposed an erythematous spot, which in a short time 
will disappear and leave no trace of its existence. If the 
vesicles are torn by scratching, or if by any other means 
their covers are removed, we shall find very superficial 
losses of substance — a moist surface covered with a 



Fig. 54 




Impetigo contagiosa circinate form. 1 

slight purulent secretion, or crusted lesions. Even this 
disappears and leaves no trace, passing through the 
erythematous stage in its course to recovery. Such 
are the appearances presented in the majority of cases. 
In adults the lesions sometimes assume a circinate form, 
but the ordinary impetigo lesions are also present. 
Besides this usual and typical form we meet with 

1 Courtesy of Dr. H. Fox. 



IMPETIGO CONTAGIOSA 385 

another and rarer variety, in which, instead of vesico- 
pustules, there are large bullae. These may be several 
inches in their long diameter, are of irregular oval shape, 
not fully distended with fluid, and sometimes show a 
slight depression in their centres. Their contents are at 
first serous, but soon become seropurulent. They seem 
to be longer preserved than the vesicles, but otherwise 
run the same course. At first they have a slight zone of 
redness about them, but this soon disappears. They 
either are formed by two or more vesicopustules running 
together, or spring up of themselves. They may attain 
their full size at once, or enlarge slowly. Rarely do 
they exist alone; generally the typical vesicopustules 
will be found in their neighborhood or elsewhere on the 
body. It is the bullous form that is liable to be mis- 
taken for pemphigus, and has been called contagious 
pemphigus. 

Impetigo contagiosa is located principally upon the face, 
most often on the chin, and on the hands; it may also 
occur upon the scalp, legs, and trunk, especially in infants. 
D. W. Montgomery 1 has met with it on the mucous mem- 
brane of the mouth, nostrils, and conjunctiva. According 
to our experience, the bullous form is most often seen 
upon the trunk. The lesions of both varieties are discrete ; 
exceptionally two or more may run together. They are 
superficial, and rarely very numerous. The bullous 
lesions are generally widely separated from one another. 
The disease does not run any definite course, and may 
last weeks or months; a slight amount of itching is 
sometimes present. 

Etiology. — It is, as its name indicates, very conta- 
gious, and often occurs in epidemics. It is readily in- 
oculable both on the subject of the disease and on others. 
Not infrequently we see a mother or other attendant 
of a child with the characteristic lesions of impetigo 
contagiosa upon the arms, derived from carrying the 
child suffering with the same disorder. Barber shops 

1 Jour. Cutan. Dis., 1910, xxviii, 345. 
25 



38G DISEASES OF THE SKIN 

are a prolific source of contagion. The contagious ele- 
ment is a streoptococcus primarily, though staphylococci 
are found also in older lesions. We know that all pus is 
under certain circumstances inoculable, and hence it has 
been maintained that there is no such disease, properly 
speaking, as contagious impetigo. But when we succeed 
in inoculating from an ordinary pustule, we produce an 
ordinary pustule, not the characteristic vesicopustule 
of impetigo contagiosa. It has been stated by some 
authorities that the disease is due to an inflammation 
set up by lice on the head of the particular case or can 
be traced back to some other case of pediculosis. In 
some cases pediculosis capitis may be present, because 
both diseases occur with special frequence in children of 
the poor. In our experience, in most cases no such 
relationship can be traced. Cases of contagious impetigo 
sometimes follow vaccination, and thus has been sug- 
gested the possible connection between impetigo and 
vaccinia. It is more frequent in the warm months than in 
the cold. Children furnish the vast majority of the cases. 

Pathology. — The pustule is roofed in by the horny 
layer, and its floor is the rete. The upper part of the 
corium displays a mild acute inflammatory reaction, with 
the usual features. By most observers the disease is 
thought to be due to staphylococcus aureus. Kauff- 
mann 1 thinks he has found a staphylococcus that differs 
from the ordinary staphylococcus pyogenes in its cultures, 
in its less resistance to destructive agencies, in its inocula- 
tions producing vesicles and not pustules, and in being 
less virulent. Sabouraud 2 and others believe it to be 
due to streptococcic infection; while still others have 
found now the one and now the other form of coccus 
in the disease. It is evident we need still more light on 
this subject. 

Diagnosis. — Impetigo contagiosa is diagnosed by the 
presence of discrete, partially distended vesicopustules, 

1 Dermat. Zeitschrift, 1899, vi, 792. 

2 Ann. de derm, et de syph., 1900, i, 62. 



IMPETIGO CONTAGIOSA 387 

which are located upon the exposed parts — head, face, 
and hands — in most cases; they are sometimes grouped; 
they run an acute course, and dry up into straw-yellow 
"stuck-on" crusts. It is sometimes preceded by slight 
constitutional disturbances, and accompanied by a 
slight amount of itching. It must be differentiated 
from simple impetigo, pustular eczema, varicella, scabies, 
pemphigus, and possibly ecthyma. 

The lesions of simple impetigo are pustules from the 
start, while those of impetigo contagiosa are first vesicles 
and then vesicopustules. The pustules of impetigo are 
prominently raised, and run no definite course. The 
vesicopustules of impetigo contagiosa are flattened, and 
run a rather definite course. The crusts of impetigo are 
generally greenish, while those of the contagious form are 
yellowish. Impetigo is not so readily inoculable as is 
impetigo contagiosa, and is much more widely dissemi- 
nated, as a rule. Simple impetigo is a deeper process 
than the contagious form. 

Pustular eczema is itchy; its pustules tend to break 
down quickly, run together, and form large patches, which 
soon become covered with a greenish or blackish crust. 
These phenomena are entirely foreign to impetigo conta- 
giosa. Eczema does not present vesicopustules nor 
bullae, as a rule. Varicella is an acute contagious disease, 
with constitutional symptoms in most cases. Its vesicles 
are smaller than those of impetigo contagiosa, and they 
run a definite course peculiar to themselves. They are 
widely distributed over the whole surface, usually appear 
first on the trunk, sometimes occur on the fauces, and not 
infrequently leave pitted scars. Contagious impetigo is 
in most cases limited to the exposed parts, it never occurs 
upon the fauces, and its lesions leave no trace. The 
crusts of varicella are small, while those of contagious 
impetigo are large. 

The diagnosis from scabies offers little difficulty. When 
we bear in mind that scabies is very itchy, that it occurs 
usually as a copious eruption upon the hands, wrists, and 



388 DISEASES OF THE SKIN 

forearms, about the umbilicus, on the nipples of females 
and the genitals of males; that scratched papules and 
pustular lesions are more characteristic of it than vesi- 
cles, and that it presents the pathognomonic furrows, we 
should not confound it with impetigo contagiosa, which 
has none of these symptoms. Further, impetigo will, in 
almost all cases, occur upon the face at the same time as 
upon the hands, and that location is very rarely attacked 
by the itch mite. 

The diagnosis from pemphigus is by no means always 
easy. The occurrence of the bullous form of contagious 
impetigo is so rare that it is no wonder it is mistaken for 
pemphigus. Indeed, it is probable that not a few of the 
cases reported as acute pemphigus in children, which pos- 
sessed apparant contagious qualities, were instances of 
this bullous form of impetigo. The diagnosis between 
the two diseases can scarcely be made with certainty by 
the appearance of the bullae alone; we must also take 
into consideration the general course of the disease. The 
differential diagnosis may be given as follows : 

Pemphigus. Impetigo Contagiosa. 

(Bullous form.) 

1. Occurs chiefly in adults. 1. Occurs chiefly in children. 

2. No source of contagion can be 2. A source of contagion can usu- 

found. ally be found. 

3. No particular sites of prefer- 3. Met with most often upon the 

ence; if anything, it is most trunk; sometimes it may oc- 

frequent on the extremities. cur on the face, hands, or ex- 

tremities. 

4. Chronic in its course; marked 4. Acute in its course, rarely last- 

by frequent relapses; may re- ing more than a few weeks, 

turn from year to year. 

5. Bullae are fully distended with 5. Bullae not fully distended, but 

a clear fluid, so that their flaccid, and contain seropuru- 

covers appear tense. They of- lent fluid. They may have a 

ten spring up out of the sound well-marked red halo while 

skin without areola. slowly attaining their full size. 

Characteristic vesicopustules 
are generally present else- 
where at the same time. 

6. Lesions often occur in great 6. Lesions few in number, do not 

numbers, so as to cover the involve the whole body, and 

whole body, and at times are itch but little, if at all. 
pruriginous. 

7. Disease obstinate to treatment, 7. Disease yields readily to treat- 

and prognosis usually grave. ment; prognosis uniformly 

good. 



IMPETIGO HERPETIFORMIS 389 

Ecthyma is probably only a form of impetigo conta- 
giosa that occurs in broken-down subjects. It affects by 
preference the lower extremities, is seen most often in 
adults, and its lesions are deep pustules which are highly 
inflammatory and painful. 

Treatment. — -The treatment of the usual form is to 
direct the affected parts to be scrubbed with warm water 
and soap to remove the crusts, and covered with a 5 
per cent, carbolized vaselin, or with oxide of zinc oint- 
ment with carbolic acid in the same strength, or with the 
ointment of the ammoniate of mercury diluted one-half. 
The last is the best. If there is a good deal of crusting, 
the crusts may readily be removed by soaking them with 
oil or warm water, after which the applications mentioned 
may be made. Salicylic acid may be used in ointment 
in 3 to 5 per cent, strength. When there is an eczema 
complicating matters Lassar's paste with salicylic acid 
answers all indications. In the bullous form it is well 
to prick the bullae at their most dependent part, and let 
the fluid escape, after which the lesions may be treated 
as just indicated. 

Prognosis. — The prognosis of impetigo contagiosa is 
always good; so readily is it cured that the patients 
seldom present themselves a third time for advice. 

Impetigo Herpetiformis. — This disease was first de- 
scribed by Hebra 1 in 1872. 

In this country it is exceedingly rare, only a few cases 
having been reported. It is from Kaposi 2 that the 
account here given is taken. 

The disease begins with an eruption of pustules in the 
genitocrural region, about the umbilicus, on the breasts, 
and in the axillse; later upon various other locations. 
The pustules are crowded together, grouped, pinhead 
size, with at first opaque and later greenish-yellow con- 
tents. They dry into a dirty-brown crust, while immedi- 

1 Wien. med. Wochenschr., 1872, No. 48. 

2 Pathologie und Therapie der Hautkrankheiten. 



390 DISEASES OF THE SKIN 

atley around them new pustules appear in double or 
threefold circles, by the drying of which the crust is 
enlarged. The disease spreads by the growth of the 
individual groups and by the coalescence of neighboring 
ones. Underneath the crusts the skin appears red and 
covered with new epidermis; or deprived of epidermis, 
moist, infiltrated and smooth; or papillary, but never 
ulcerated. Within three or four months the whole 
cutaneous surface is involved, swollen, hot, covered with 
crusts, showing torn and excoriated places, with here 
and there circles of pustules. The mucous membrane 
of the tongue may show circumscribed gray patches. 
There is a continuous remittent fever, and each outbreak 
of pustules is marked by chills, high fever, and dry 
tongue. Nearly all cases prove fatal. The disease has 
affected almost exclusively pregnant women, few men 
having been reported with the malady. Delivery has 
not stopped the course of the disease. It is probably 
of septic origin. 

Diagnosis. — The disease is stated by Kaposi to differ 
from dermatitis herpetiformis in being only pustular; in its 
peculiar location and manner of spreading; in the absence 
of itching; in the severe constitutional symptoms; and in 
its lethal ending. 

Treatment. — No treatment has proved successful. 
We can only do our best to nourish the patient; and by 
means of baths, dusting powders, or alkaline lotions, 
render her as comfortable as possible. 

Intertrigo. — See Erythema intertrigo. 

Iodic Acne. — See Dermatitis medicamentosa. 

Itch. — See Scabies. 

Keloid. — Synonyms: Kelis; (Fr.) Cancer tubereux, 
Cheloide; (Ger.) Knollenkrebs. 

A connective-tissue new growth in the skin, occurring 
most commonly upon the chest; characterized by hard- 
ness, by a pinkish color, and by sending off prolongations 
in all directions (Fig. 55). 



KELOID 



391 



Symptoms. — It is usual to divide keloids into two 
varieties, one of which is called the true or spontaneous 
keloid, and the other the false or secondary keloid the 
result of injuries. Of late the opinion is gaining ground 
that no such distinction can be made, and that even the 
true keloid results from some slight injury. As most 
commonly met with, it consists of a single, firm, hard, 

Fig. 55 




Keloid. 



pinkish, freely movable, oval or elongated, elevated tumor 
upon the upper half of the sternum, from which claw-like 
processes are given off in all directions. While there may 
be but one tumor, the lesions may be multiple, there 
being either one large and several small ones upon the 
chest, or many scattered over the body. They begin as 

1 From G. H. Fox's Photographs of Skin Diseases. 



392 DISEASES OF THE SKIN 

small pinkish elevations and gradually enlarge until they 
attain a certain size, when they may remain stationary or 
else slowly grow. They assume all sorts of shapes and 
sizes. Sometimes they have an even surface, sometimes 
they are nodular. They may be quite small, or they may 
be so large as to run nearly half-way across the chest. 
Then the appearance is as if the skin were drawn up 
into the tumor. The epidermis is smooth over them, and 
the pink color is due to dilated bloodvessels. Sometimes 
the color is white. Though they are rarely met with on the 
face of the white races, they are very common upon the 
face of the negro. They are often attended by a good 
deal of pain, or pruritus, or pricking sensations. 

Beside this form of keloid, that may or may not be 
spontaneous, we have the evident scar keloids that occur 
over the site of an injury to the skin. These have fol- 
lowed syphilids that have destroyed the skin, variola 
pustules, psoriasis, a blister, or acne. 1 They may be 
limited to the site of the previous lesion or spread beyond 
it. This form of keloid is very often seen on the face of 
the male negro who shaves, the cheeks and chin being 
studded over with small, hard, white elevations. The 
hypertrophied scar resembles keloid, but never spreads 
beyond the limits of the injury, has no claw-like pro- 
cesses, is not so pinkish nor so permanent. 

Keloids very rarely ulcerate or change into malignant 
growths. But it is not uncommon for epithelioma to 
develop on hypertrophic scars. 

Etiology. — We know scarcely anything as to the 
cause of keloid, and can only beg the question by saying 
that it is a predisposition on the part of the skin. It is 
probable that some minute injury precedes the tumor. 
The negro race is peculiarly prone to the disease. Sex is 
without influence, and it may occur at any age, though 
rare before puberty and in old age. Histologically the 
structure of the keloid is similar to that of the cicatrix — 

1 Purdon: Jour. Cutan. and Ven. Dis., 1882-83, i, 203. 



KELOID 393 

that is, it is a dense fibrous connective-tissue growth 
which has its seat in the true skin. 

Treatment. — As a rule, it is safest to leave the 
growths alone. Cutting them out is often disappointing 
in its results, as they are apt to return. Multiple scari- 
fications followed by the application of acetic acid have 
been successful. Leloir and Vidal 1 recommended follow- 
ing multiple scarifications with a boric-acid dressing. 
The next day mercurial plaster is to be applied, and 
changed every morning and evening. Perseverance in 
this method, they say, may result in a cure. Compres- 
sion by means of an elastic bandage or by mercurial 
plaster sometimes reduces the prominence of the tumors. 
Hardaway has succeeded in removing one keloid and two 
hypertrophied scars by means of electrolysis, and Brocq 
has commended the method. A stout needle must be 
used and multiple punctures made in all directions, and 
in the tissues for a space beyond the tumor. Galvanism 
is said to reduce hypertrophied scars. Balzer and Mous- 
seaux 2 recommend the use of a 20 per cent, solution of 
creosote in oil. A cubic centimeter of the solution is to 
be injected into many points until the tumor pales. This 
is followed by inflammation, swelling, and sloughing off 
of a portion of the keloid, and rather deep ulceration. 
After a few days the ulcerations are healed and the injec- 
tions are repeated. Andeer 3 recommends resorcin and a 
bandage. S. Tousey 4 advocates the use of thiosinamin, 
and reports some favorable cases. It may be used either 
hypodermically once a day or every other day, 12 to 15 
minims of a 10 per cent, solution in equal parts of pure 
glycerin and sterilized water; or by mouth, 3 grains (0.2) 
being given during the day. We have tried this treat- 
ment in a number of cases without benefit. L nna recom- 
mends thiosinamin plasters. The use of x-rays has been 
followed by the disappearance of a number of keloids. 

1 Ann. de derm, et de syph., 1890, i, 193. 2 Ibid., 1898, ix, 1147. 

3 Centralbl. f. med. Wissenschaft, 1888, xxvi, 785. 

4 New York Med. Jour., 1897, lxvi, 624. 



394 DISEASES OF THE SKIN 

Pusey advises daily exposures, on every second or third 
day, gradually carried to the point of producing an ery- 
thema unless the growth subsides. It takes from one 
to six months to remove them. The massive dose might 
be used. Ravaut 1 reports good results from the use of 
hot air produced by the Gaiffe apparatus. Fibrolysin is 
also advised. Hypodermic injections of morphin, or the 
application of belladonna ointment, may be necessary to 
relieve pain. 

Prognosis. — It is possible for hypertrophied scars to 
undergo spontaneous involution. This is especially the 
case in the scar keloid following syphilis. Usually this 
cannot be expected in true keloid. 

Keloid of Addison.— See Morphea. 
Keloid of Alibert. — See Keloid. 
Keratodermia Excentrica. — See Porokeratosis. 

Keratodermia Gonorrhoica. — In some cases of gonorrhea, 
especially those with severe articular and general manifes- 
tations, there occurs upon the hands and feet, rarely on 
the trunk, an eruption of keratotic growths. On the feet 
there is a thickening of the corneous layer of the soles, 
especially along the border. The dorsal surface of the toes 
may be affected. Irregular horny masses with uneven 
surfaces form. The skin is brownish yellow, upon which 
are brown or purplish-brown nodules y 3 0- to 2 cm. in 
diameter. With the cure of the gonorrhea the masses 
scale off and disappear. 

Keratolysis Exfoliativa is the name applied by A. 
Sangster 2 to a case of congenital exfoliation of the skin 
which resembled ichthyosis, excepting that its scaling 
was more papery, like that seen in dermatitis exfoliativa. 

Keratosis Follicularis. — Synonyms: Ichthyosis sebacea 
cornea (Wilson) ; Ichthyosis follicularis (Lesser) ; Darier's 

1 Annal. derm, et syph., 1910, i, 145. 

2 British Jour. Dermat., 1895, vii, 37. 



KERATOSIS FOLLICULAR! S 395 

disease; Psorospermosis; Psorospermose folliculaire 
vegetante; Acne sebacee cornee. 

Symptoms. — This disease affects nearly the whole 
cutaneous surface, though in White's 1 case the .palms 
and soles were free. It frequently is first seen on the 
face. The eruption begins as pinhead-sized papules, 
which are firm and of the color of the skin, looking like 
keratosis pilaris. As they increase in size they become 
hyperemic; still growing, they become hemispherical 
or flattened, with smooth or polished, dense adherent 
coverings of nail-like consistence, and varying in color 
from dull red to purplish, dusky-red, brown, and brown- 
ish-black. Some of them are excoriated by scratching 
and bear hemorrhagic crusts. These lesions are discrete 
and the skin about them normal. They are located in 
the hair follicles. In places the lesions run together and 
form elevated areas with uneven surfaces, covered by 
thick yellowish or brownish, flattened horny concretions; 
or there may be brownish or blackish plates. The patches 
feel rough and somewhat greasy. Here and there, 
especially in the inguinal, genital or anal region, will 
be found papillomatous excrescences; or enormously 
dilated follicular openings filled with comedo-like, firm, 
slightly projecting concretions forming hemispherical 
elevations, which when expressed are found to be hard 
and perfectly dry, leaving the follicle mouth patulous. 
It spreads gradually and in course of years it may become 
generalized. The nails become coarse, slightly thick- 
ened, and ragged at their free edges. Boeck 2 says that 
they are often the seat of a marked hyperkeratosis with- 
out a trace of the disease itself anywhere in their neigh- 
borhood. The hard palate in White's case showed some 
follicular elevations. Pruritus is marked in some cases. 
A fetid odor is given off from the patient. 

Upon the scalp the disease may appear for a long time 
as a pityriasis steatodes, but later the same elevations 

1 Jour. Cutan. and Gen.-Urin. Dis., 1889, vii, 201. 

2 Arch. f. Dermat. u. Syph., 1891, xxiii, 857. 



396 DISEASES OF THE SKIN 

about the hairs can be made out as are seen upon the 
general integument. Upon the back of the hands and 
fingers the eruption presents the appearance of simple 
papillary growths, little pale-white, slightly raised, con- 
fluent and adherent masses. This is one .of the char- 
acteristic lesions of the disease. Upon the palms and 
soles, instead of elevations, we find punctate depressions, 
and perhaps a hyperkeratosis. Hyperidrosis is often 
marked. In the axillae, on account of maceration by 
sweat, the masses are not so hard and horny, and the 
scales can be rubbed off, when a moist, red, warty surface 
is exposed. 

The course of the disease is a progressive one by the 
springing up of new lesions. It develops symmetrically. 
It seems to have no damaging effect on the health. It 
affects especially the scalp, axillae, inguinal region, abdo- 
men below the umbilicus, back of the hands and feet, and 
the wrists. 

Etiology.— We know nothing positive about the eti- 
ology of this rare affection. White met with it in a father 
and daughter, and Pohlmann 1 reports five cases occur- 
ring in three generations of one family. This suggests 
heredity as a cause. The disease may begin at any age, 
cases having been reported as commencing in the first 
weeks of life, in the sixth, sixteenth, twenty-second, 
twenty-seventh, and thirty-sixth years, though most 
cases occur before the twenty-fifth year. Males are 
more often affected than females. 

Pathology. — J. T. Bowen, who made a careful ex- 
amination of White's first case, says that "the disease is 
a keratosis of the epithelial lining of the mouths of the 
follicles, which, by extension downward, gradually pro- 
duces pouch-like depressions in the corium. The capacity 
for corneous metamorphosis is so great that the central 
portion becomes a firm horn, which by production of 
horny matter from below is gradually pushed out above 

1 Archiv. Dermat. u. Syph, 1909, xcvii, 195. 






KERATOSIS FOLLICULARIS CONTAGIOSA 397 

the surface of the skin. There was no proof that the 
sebaceous glands were affected by the horny change." 
The keratosis may occur outside of the mouths of the 
follicles. 

Diagnosis. — The disease differs from pityriasis rubra 
pilaris in lacking the constant and early involvement of 
the palms and soles ; in the absence of the isolated papules 
pierced by hairs on the dorsum of the fingers; and the 
extensive, diffused, scaly dermatitis of the face, neck, and 
other parts; and in having horny plugs. It differs from 
acanthosis nigricans in not affecting the mucous mem- 
branes ; not having warty, deeply pigmented growths, and 
not being associated with visceral disease. 

Treatment. — The proper treatment is yet undeter- 
mined. It might be well to try the methods found 
useful in ichthyosis. X-rays have benefited some cases. 

Prognosis. — It is always a very obstinate disease 
and prone to relapses. The general health is not affected 
as a rule. Epitheliomas have developed in exceptional 
cases. 

Keratosis Follicularis Contagiosa. — This is a rare disease 
that was first described by Brooke. 1 

It is akin to keratosis follicularis, and some cases 
described as acne sebacee cornee. According to Brooke's 
description the first change in the skin is a thickening 
of the corneous layer so that there is an accentuation of 
the little rhomboid spaces of the skin. Minute black 
specks appear in them, some of which develop into pap- 
ules from the top of which spines protrude. The spines 
are long and thin like bristles; others are short and thick 
like comedones. When extracted pit-like depressions 
are left. These give the skin a rough, nutmeg-grater 
feel. Some of the larger papules become inflamed and 
resemble acne pustules, while others assume a warty 
appearance. The lesions may aggregate into patches 
which are rough to the feel, the skin about them having 

1 Internat. Atlas of Skin Diseases, 1892, part vii, plate xxii. 



398 DISEASES OF THE SKIN 

a dirty yellowish-brown color. The disease is symmetrical 
and is found chiefly on the nape of the neck, the shoulders, 
and extensor aspects of the limbs. It may be found 
anywhere on the body. 

Etiology and Pathology. — It occurs most often in 
children and is contagious, spreading through a family. 
It is a hyperkeratosis affecting chiefly the follicles, and 
extending to the other epithelial layers. 

Treatment. — Softening of the skin by an ointment 
containing an alkali such as carbonate of soda, or potash 
will remove the lesions. Relapses may occur. 

Keratosis Palmaris et Plantaris. — Synonyms: Keratoma 
palmare et plantare hereditarium ; Ichthyosis palmaris 
et plantaris; Tylosis palmse et plantse. 

This is a form of congenital or acquired callositas. It is 
characterized by the appearance upon the palms and soles 
of masses of thickened skin of leathery consistence and yel- 
low or brown color. They come without apparent cause, 
and usually show a symmetrical arrangement. The palms 
or the soles alone may be affected, but it is always both 
palms or both soles that are affected. There is sometimes 
a zone of redness about the thickened plates. Sometimes 
the whole palm or sole is covered, sometimes the horny 
masses occur in islands. The plates may be shed period- 
ically, only to reform. The surface of the plates may be 
smooth or uneven. Exceptionally the disease spreads 
on to the dorsal surface. Hyperidrosis is frequently 
marked. The nails at times show hypertrophic changes. 
Pain may be complained of when the hands or feet are 
used. If the feet are affected, the pain may be so great 
as to prevent walking. 

Etiology. — The disease is hereditary in many in- 
stances, and congenital, and like ichthyosis tends to 
affect only one sex in the family. We do not know its 
cause, and we class it as a trophoneurosis. It some- 
times has been noted to follow the prolonged ingestion 
of arsenic. Its pathology is the same as that of callositas. 



KERATOSIS PILARIS 399 

Treatment. — Little benefit is to be expected from 
internal treatment. Brocq advises large doses of arsenic; 
Brooke has found ichthyol, 3 drops t. i. d. of use; and 
Klotz gave pilocarpin in one case with benefit. The 
plates may be removed by salicylic acid plaster or oint- 
ment, 10 to 20 per cent, strength. The same end is 
reached by poultices, the wearing of rubber sheeting, 
and the application of various plasters. A permanent 
cure can hardly be expected. In some cases z-rays have 
removed the thickening. 

Keratosis Pilaris. — Synonyms: Lichen pilaris; Pity- 
riasis pilaris; Ichthyosis seu hyperkeratosis follicularis; 
Cacotrophia folliculorum; (Fr.) Xerodermic pilaire, Ich- 
thyose anserine des scrofuleux. 

Symptoms. — As its name indicates, this is a disorder 
of cornification. It is characterized by a heaping up of 
the corneous cells about the mouths of the hair follicles 
in the form of small conical, whitish or grayish elevations. 
Between them the texture of the skin is normal; its color 
may be unchanged or rosy, or of a grayish or brownish 
shade. It occurs chiefly upon the extensor surfaces of 
the limbs, especially upon the upper arm and thigh, but 
may occur anywhere. The appearance of the affected 
part resembles cutis anserina, being dotted over with pin- 
head- to small-pea-sized papules, each one of which is 
either pierced by a hair or has a black dot at its summit 
indicating the mouth of the hair follicle. The papules 
are often scaly. The hair is either normal, broken off, 
or only to be found by opening the papule, when it will 
be seen curled up inside of it. The skin feels dry and 
harsh. There may be slight pruritus. Pityriasis capitis 
may be present at the same time. As the disease is 
attended by but slight, if any, subjective symptoms it is 
often overlooked. It is a chronic affection in most cases, 
though it often is much less pronounced in warm weather 
when sweating is increased. 

Brocq describes a keratosis pilaris of the face begin- 



400 DISEASES OF THE SKIN 

ning as minute scaly papules about the hairs, which crowd 
together to form patches and give a rosy red tint to 
the skin. After a time the disease seems to destroy the 
follicle, and we find depressed scars arranged in rows or 
scattered about on the red patch. This bears some 
resemblance to lupus erythematosus, and is the ulery- 
thema ophryogenes of Taenzer. Besnier describes a 
somewhat similar condition as occurring upon the 
extremities. 

Etiology. — The disease is sometimes congenital and 
often forms a part of ichthyosis. It is most common in 
women, and those who do not bathe frequently, or in 
whom there is a dry or a peculiarly coarse quality of skin. 

Pathology. — According to S. C. Boeck 1 the lesions 
are due to a markedly increased growth of corneous 
cells within the hair follicles and in that part of the sweat 
duct that lies within the epidermis, with the development 
of horny plugs in the mouths of the hair follicles and 
sweat pores, forming papules. 

Diagnosis. — It differs from cutis anserina in being a 
permanent condition; from the miliary papular syphilid 
in being whitish, grayish, or blackish, and not dark-red 
or raw-ham color, and in being removable by soap and 
water. Lichen scrofulosorum occurs in strumous subjects 
and in well-marked circular or crescentic patches, which 
is foreign to keratosis. Papular eczema differs in being 
very itchy, and in having red inflammatory lesions. 
Ichthyosis is a general affection of congenital origin, 
has peculiar markings of the skin, and is not limited 
to the hair follicles. Lichen pilaris (Crocker) has red 
patches at the beginning, spiny plugs, and occurs in 
patches. 

Treatment. — The vigorous use of green soap and 
water in an alkaline bath, followed by oil or vaselin, 
will remove the evidences of the disease. Vapor or 
Russian baths may be used for the same purpose. Hyde 

1 Dermat. Wochenschrift, 1912, Iv, 1459. 



KERATOSIS SENILIS 401 

prefers general cool baths containing J of a pound of 
common salt to each gallon of water, after taking which 
the skin is to be rubbed with a coarse towel or flesh- 
brush. As the affection is allied to ichthyosis, it may be 
treated on the same plan. 

Keratosis Senilis. — This malady may occur as a slight 
thickening of the corneous layer of the skin in the form 
of thin, dirty or brownish-gray plates, bean size or larger, 
which are adherent to the skin, but at first can be readily 
rubbed off, leaving a moist or oily surface. They soon 
re-form, and in course of time, if frequently removed, 
it may be noticed that the base shows small bleeding 
points, later a superficially ulcerated surface, and still 
later all the signs of an epithelioma. 

Or it may take the form of warty outgrowths, of dirty 
brown or black color, which are hard, and when picked 
off crumble in the fingers. These also in course of time, if 
frequently removed, may undergo epitheliomatous changes. 
Both forms may be more or less greasy in character. 
Their first stage may be a lentil-sized or larger pigmentary 
patch. They are most often located on the face or the 
backs of the hands, locations most exposed to the action 
of sunlight. If irritated by attempts at picking them 
off they may be converted into epitheliomas. 

Etiology. — Senility of the skin is the cause of the 
disease. While they occur most often after sixty years 
of age, they may occur at a much earlier age, at any 
time after middle life. It is probable that lack of care 
of the skin, and exposure to the sunlight are active 
causes in their production. It is said that they are seen 
in farmers and out-door workers in the country more 
commonly than in city dwellers. 

Treatment. — When small and when they are com- 
paratively young they may be removed by the use of an 
ointment containing 1 to 5 per cent, of salicylic acid, to 
which may be added precipitated sulphur in like amount. 
If they are hard they had best be let alone, or treated as 
if they were epitheliomas by currettage and caustics, or 
26 



402 DISEASES OF THE SKIN 

arrays. It must be borne in mind that the senile skin 
bears the rays badly, and they must be used with caution. 
Freezing by carbon dioxide snow removes them perfectly 
with scarcely perceptible scar. 

Keratosis Spinulosa. — See Lichen pilaris of Crocker. 

Kerion.- — Synonyms: Trichomykosis capillitii; Tinea 
kerion; Kerion Celsi. 

Symptoms. — This is a more or less chronic inflamma- 
tion of the scalp or beard that most often is a form of 
ringworm, but may be produced quite independently of 
that disease. It is most commonly seen on the scalp. 
The affected part becomes red, edematous, swollen, and 
boggy, and may assume a purplish color. Its surface is 
glazed, uneven, and studded with a number of yellowish 
suppurating points, or with foramina out of which oozes 
a sticky, viscid, gelatinous, transparent fluid. Sometimes 
suppuration may occur attended by a seropurulent 
discharge. The swelling is round or oval in shape, and 
varies in size; it may be but one or two inches in diam- 
eter, or as large as a turkey's egg. The pustules form 
about the hair in the early stage; later the hairs fall and 
the discharge takes place from the openings of the hair 
follicles. If the tumor is opened, a thick, viscid material 
escapes. If the disease occurs with ringworm, the hair 
will be broken off. Permanent baldness may result 
if the inflammation is intense. There are more or less 
pain and tenderness, and at times itching and burning. 
The posterior cervical glands may be enlarged. 

Etiology. — The disease is comparatively rare. It 
occurs chiefly in children of poor constitution. It is 
most commonly due to the trichophyton fungus passing- 
deep down into the hair follicles. In most cases the 
fungus is of animal origin. It ma}' be caused by the 
application of irritants to the scalp, or follow eczema, 
favus, or folliculitis of that part. 

Diagnosis. — Kerion must be diagnosed from an 
abscess, a papilloma, a gumma, and a sebaceous cyst. 



KOILONYCHIA 403 

An abscess is not preceded by ringworm, has no history 
of an irritant applied to the scalp, and may arise without 
any antecedent disease of the scalp; it is more painful; 
it is often accompanied by a sensation of throbbing, by 
chilliness, fever, and general malaise; when fully formed 
there is fluctuation, and when opened it gives exit to pus. 
These symptoms are not met with in kerion. A papilloma 
is non-inflammatory, firm to the touch, and is unaccom- 
panied by a discharge. A gumma is usually accompanied 
by other signs of syphilis, and tends to break down and 
ulcerate. A sebaceous cyst is slow in its growth, the skin 
over it is normal, there is no discharge, and when opened 
it gives vent to a cheesy mass. A fatty tumor is a chronic, 
elastic, freely movable swelling, with normal skin 
over it. 

Treatment. — In treating a case, epilation should be 
performed in order to save the hair and give exit to the 
discharge. If some irritant application is the cause, that 
should be discontinued, and hot-water dressings with 
boric acid, antiseptic solutions, or mild emollient applica- 
tions employed. If the cause is ringworm, the remedies 
proper for that disease should at once be used. What 
they are will be found under Trichophytosis capitis. 

Prognosis. — The disease is curable, though sometimes 
with difficulty. Many cases get well of themselves. 
It may cause permanent baldness. 

Koilonychia, or Spoon Nails, is a condition of the nail in 
which it becomes more or less concave from side to side, 
sometimes anteroposteriorly. The nail is thin and easily 
bent, its surface is furrowed, and its free border irregularly 
notched. Its color is whitish, its edge being dirty gray. 
It begins on one finger and gradually affects all the nails. 
It is often associated with leukonychia. The nails are 
easily broken. There is often a subungual keratosis at 
the free borders of the nails. It is a chronic disease, and 
may be hereditary; or acquired, as from having the hands 
much in water. 



404 DISEASES OF THE SKIN 

Kraurosis Vulvae is the name proposed by Breisky 1 for a 
form of atrophy of the skin of the external genitals of 
women, which may occur at any age. The disease has its 
seat in the vestibule, the labia minora with the frenulum 
and preputium clitoridis, the inner surfaces of the labia 
majora up to the posterior commissure, and the contiguous 
skin of the perineum. It gives rise to the appearance of 
a defect in the development of the normal folds of the 
vulva. At times the labia minora and the preputium 
clitoridis are apparently wanting. The affected skin is 
white and dry, the epidermis is often thickened, and tel- 
angiectasic vessels are visible. Stenosis of the vulvar 
entrance may result, and thus obstruction be offered 
both to coitus and parturition. The cause is obscure; 
possibly a long-continued blennorrhea, or a congenital 
defect, or a process analogous to leukoplakia buccalis. 
Thibierge 2 teaches that it is a disease that develops in 
those whose ovarian activity has ceased either on account 
of the menopause or removal of ovaries. Treatment is 
of no effect. 3 

Lentigo. — Synonyms: Ephelides; (Ger.) Sommerspros- 
sen, Linsenflecke; Freckles. 

Freckles are properly a species of chloasma. They 
occur as light to dark-brown or even black macules, and 
are usually located upon exposed parts, especially the face 
and back of the hands, but they may occur anywhere. 
In size they vary from that of a pinhead to that of a split 
pea. They give rise to no subjective symptoms. They 
usually do not appear before the eighth year of life, but 
congenital cases have been reported. The latter should 
rather be classed among the pigmentary nevi. A division 
is sometimes made between those that are permanent and 
occur upon unexposed places and those which occur in 
summer to disappear in winter. To the former the name 
lentigo is given, and to the latter ephelides. As old age 

1 Zeitschrift f. Heilkunde, 1885. 

2 Annal. Derniat. et Syph., 1908, xix, 1. 

3 Janovsky, Monatshefte f. prakt. Dermat., 1888, vii. 951. 



LENTIGO 405 

is approached freckles no longer form, and the old ones 
are apt to disappear. 

Lentigo maligna is a form of lentigo that comes in old 
age in the form of dark-brown, small, irregular spots of 
pigment that occur on the eyelids, and even the conjunc- 
tiva, and coalesce into patches which later may change 
into an epithelioma. 

Etiology. — The cause of freckles is probably an 
inborn peculiarity of the skin. It has been advanced as a 
theory of their production that they are due to the chemi- 
cal action of the sun's rays upon the blood. Blondes are 
more prone to them than are brunettes. Many people 
never freckle. Symptomatically they occur as part of 
atrophoderma pigmentosum. 

Pathology. — Freckles are but circumscribed deposits 
of pigment. Cohn 1 has endeavored to show that len- 
tigines differ from ephelides in being discrete, slightly 
elevated, and having their pigment in all the layers of the 
epidermis, as well as in the cutis, and in being associated 
with changes in the bloodvessels of the cutis; while 
ephelides are crowded together, their pigment is only in 
the basal layer of the epidermis, and there are no changes 
in the bloodvessels. 

Treatment. — The treatment of freckles is the same 
as that of chloasma. The only prevention is to protect 
the skin from the action of the sunlight by wearing veils 
or by the use of some lotion containing a pigment, such 
as calamin lotion, or a brown grease paint. Hardaway 
recommends for their removal the following: 



R — Hydrarg. ammon., 

Bismuthi subnitrat., aa, 3J aa 4 

Ungt. aq. rosse, ad gj ad 32 



M. 



He speaks highly also of electrolysis for the removal 
of very black freckles. Bulkley recommends the fol- 
lowing : 



, — Hydrarg. bichlor., 


gr. vj 






4 


Acid, acetic, dil., 


5ij 




8 




Ac. boric, 


gr. xl 




2 


5 


Aquae rosae, 


ad 3iv 


ad 


128 


M 



Monatshefte f. prakt. Dermat., 1891, xii, 119. 



406 DISEASES OF THE SKIN 

This is to be used night and morning, at first gently, but 
afterward to be well rubbed in. The skin may be caused 
to exfoliate superficially by dabbing on the skin two or 
three times a day an aqueous solution of bichloride of 
mercury, J to 4 grains to the ounce. As soon as scaling 
begins the lotion should be discontinued. Stelwagon 
prefers : 

1$ — Hydrarg. bichlor., gr. iv-viij 0.26-0 [52 

Tinct. benzoin., 3 i J & 

Zinc, sulphat., gr. xx-xl 1.33-2 65 
Alcohol, 

Aquae, aa p. e. ad Siv 128 M. 

used in the same way. Peroxide of hydrogen bleaches 
them. They may also be touched with dilute acetic or 
lactic acid, trichloracetic acid, or with pure carbolic acid. 

There is hardly any use in endeavoring to cure freckles 
occurring from the action of the sun, as they depart of 
themselves. 

Lepothrix. — Synonyms: Trichomycosis palmellina sen 
nodosa; Nodositas pilorum microphytica. 

Symptoms. — Various colored nodes surrounding the 
hair are found in subjects who sweat profusely. These 
are met with most frequently in the axillae, then upon the 
chest, pubes, and inside of the thighs. They are grayish, 
yellow, yellowish red, or brown. When the hair is dry 
they are hard. They may be located anywhere on the 
hair but do not invade the follicle. In slight grades the 
hair is thickened, sometimes to twice its normal size 
by a sticky mass that surrounds it, or is deposited on it 
in knobs. It may be normal in length, or shortened and 
end in a knob. From freshly plucked hair the mass may 
be shaved off with ease, but when the hair is dry it is 
apt to be injured by removing the deposit. Both the 
cleanly and the uncleanly show these nodes, blondes 
being affected more than brunettes. In this country 
the disease is not often seen. 

Etiology. — The cause of the disease is the lodgement 
on the hair of a species of schizomycetes forming zooglea 



LEPRA 407 

masses. They may be simply deposited on the hair, 
or attached to a scale at its angle of attachment. In 
growing the parasite may penetrate to the cortex of the 
hair and split it into fasciculi. It is predisposed to by 
excessive sweating. Bacterium prodigiosus is the cause 
of red sweat. 

Treatment. — A cure is readily effected by washing 
the part with soap and water, and bathing with bi- 
chloride of mercury solution 1 in 1000 or a saturated 
solution of boric acid. The latter is best for blonde 
patients as their skin is apt to be easly irritated. 

Lepra. — Synonyms: Elephantiasis Grecorum; Leonti- 
asis; Satyriasis; Lepra Arabum; (Fr.) La Lepre; (Ger.) 
Der Aussatz; (Norweg.) Spedalskhed; Leprosy. 

A chronic, endemic, constitutional disease due to 
infection by a specific bacillus ; characterized by anesthe- 
sia, erythematous patches, tubercles, ulcerations, atro- 
phies, and deformities according to the structures most, 
affected; and ending in death. 

Symptoms. — It is usual to describe three forms of 
leprosy — the tubercular, the maculo-anesthetic, and 
the mixed. This is convenient for clinical purposes, 
though not absolutely correct, as even in the nearly pure 
tubercular form there is more or less anesthesia. All 
forms exist in all endemic regions, but now one and now 
another form predominates. The tubercular form is the 
one most common in cold countries, the anesthetic in 
hot countries. Morrow, 1 however, found that in the 
Hawaiian Islands the tubercular form constituted one- 
half of the cases, while the anesthetic form formed but 
one-third of them. 

The incubation stage is undetermined. It may be 
several months or many years. During this stage there 
are no special symptoms. 

Tubercular Leprosy. — Sometimes this form appears sud- 
denly without prodromata, but usually for days, weeks, or 

1 New York Med. Jour., 1889, 1, 85. 



40S 



DISEASES OF THE SKIN 



months, before the disease frankly declares itself the 
patient[is out of health. He feels indefinitely ill, depressed, 
and listless; he has dyspepsia and diarrhea; he is weak, 



Fig. 56 




Tubercular and anesthetic leprosy. 1 

chilly, and suffers from profuse sweating. There may be 
nosebleed. Frequently the first, and generally unrecog- 



1 From a photograph kindly loaned me by Dr. P. A. Morrow, of 
New York. 



LEPRA 409 

nized symptoms of the disease are a husky voice, and a 
nasal discharge, showing an early implication of the 
mucous membranes. Then a remittent fever of malarial 
type appears. This fever may occur without the other 
prodromas, and may recur with each new outbreak of 
tubercles. It ranges from 99° to 106° F. It may last 
from several days to several weeks. After a time an 
erythematous eruption appears upon the face, ears, 
the forearms, and thighs. It consists of purplish or 
mahogany-red, slightly raised, hyperesthetic, smooth, 
shiny patches, of one or several inches in diameter, 
usually of oval form. The eruption may fade entirely 
away, to appear again with a fresh outbreak of fever. 
After some three to six months of the exanthem the 
tubercles appear, either upon the sites of the previous 
lesions, or quite independently of them. They begin as 
pinhead-sized pink papules that enlarge to split-pea- or 
even to hen's-egg-sized, yellowish-brown tubercles. If a 
number of these run together, large infiltrated patches 
are formed of irregular shape and nodular surface. 
Infiltrations may also arise by an increased deposit of 
leprous material in the macules, for the macules them- 
selves are formed of leprous material, and are not 
simply erythematous lesions. Sometimes the infiltrated 
patches that arise from the macules may assume ring 
shapes, by clearing up in their centres. The tubercles 
are completely anesthetic. They may come anywhere, 
but are most commonly seen in the eye-brows, lobes of 
the ears, the face generally, and upon the extremities. 
They are rare on the glans penis, palms, and soles. The 
scalp is said never to be affected. The mucous mem- 
branes of the mouth, nose, larynx, trachea, uterus, and 
vagina are also involved, as may be the conjunctivae. 
The tubercles may undergo spontaneous involution 
in one place, while fresh outbreaks of them occur in other 
places. Or they may soften and break down and form 
leprous ulcers, which are indolent, sharply defined, 
and glazed over with a mucous discharge of a peculiar 



410 DISEASES OF THE SKIN 

odor. These may attain enormous dimensions, becoming 
serpiginous and phagedenic. When these ulcers go deep, 
as they may do on the lower extremities especially, there 
may take place spontaneous amputation of the fingers, 
toes, or whole members. This is one form of mutilating 
leprosy, which is most frequently encountered in the 
anesthetic form of the disease. Or the tubercles may, 
on disappearing, leave atrophic spots. Their develop- 
ment and involution are always slow. 

The appearance of a well-developed case is striking. 
The face is deformed by the tubercles, and assumes the 
"leonine" expression on account of the thickening of the 
eye-brows causing them to protrude, so that the eyes 
are sunken and have a stern expression. The hair is 
wanting in the eye-brows. The immense lobes of the ears 
hang down. The lips protrude and are often everted. 
Tubercles stud the face. The forearms are enlarged and 
knobby. The hands are deformed. There is very com- 
monly a discharge from the nose, a disagreeable odor 
from the mouth, and the sense of smell is lost. The 
eye-sight is often lost; the voice is cracked and croaking. 
The lymphatic glands are often swollen. Happily, both 
in men and women sterility is the rule. There are com- 
monly atrophy of the testicles and loss of sexual power 
in men. The disease is steadily progressive, and death 
occurs in eight years on an average, though the disease 
may last for many years. Crocker says 40 per cent, 
die of the disease itself, 40 per cent, die from renal or lung 
complications, and the rest from diarrhea, anemia, or 
general marasmus. 

Maculo-anesthetic leprosy announces its onset not by 
febrile symptoms, but by shooting, lancinating pains in 
the chief nerve trunks, as the ulnar, median, peroneal, 
and saphenous. There are also pain and tenderness in 
various places, and a state of general hyperesthesia. 
Itching is regarded by Morrow as being one of the most 
common and characteristic prodromas of this form of 
leprosy. There may also be symptoms of general malaise 



LEPRA 



411 



and digestive disturbances. A frequent early symptom 
is a vesicular or bullous eruption upon the fingers and 
toes, with at first serous, then purulent contents. These 
may burst and leave a white, shining, anesthetic spot, 
or an ulceration that heals with an anesthetic cicatrix. 
Numbness soon follows the hyperesthetic state. The 

Fig. 57 





Macular leprosy 



patient cannot grasp things firmly, and the consequent 
unskilfulness of his action may be the first thing to 
attract his attention. This shows muscular weakness as 
well as numbness. 

After some months of these prodromal symptoms an 
eruption of macules similar to those of the tubercular 



412 DISEASES OF THE SKIN 

variety appears upon the extremities, face and back. 
They are isolated, of oval shape, hardly raised above the 
surface, and of a pale-yellow to reddish-brown color. 
They may be quite small or of large size. These often 
enlarge peripherally and clear up or become atrophic 
in the centre, forming rings. The macules become 
intensely red, and enlarge during the outbreaks of leprous 
fever, which occurs as in the tubercular form. Sometimes, 
instead of being oval, they will take the form of wide 
streaks or of gyrate figures. They are often hyperesthetic 
when newly formed, but always perfectly anesthetic 
when they have become atrophic, and even before that 
in cases that have lasted some little time. The large 
nerve trunks, as that of the ulnar, are at first hyper- 
esthetic, but later are anesthetic and can be felt like a 
whip-cord and rolled about under the finger without 
giving rise to pain. Anesthetic areas w'ill be found 
independently of the macules and in old cases a rather 
general anesthesia develops, so that the patient may 
burn himself without noticing it. The anesthetic areas 
are subject to change from time to time. Solitary bullae 
appear from time to time, as well as urticaria-like lesions. 
Marked atrophy of the muscles of the hands and feet 
occurs, and paralysis of the extensor muscles of the 
second and third phalangeal joints. Wasted interossei 
muscles and permanent flexion of the last phalanges 
of the fingers give as characteristic an expression to the 
hand in this form of leprosy as the tubercles do to the 
face in the tubercular form. 

After some ten years or so, during which the greater 
part of the cutaneous surfaces may have become studded 
over with white, wrinkled, hairless, atrophic spots, the 
permanent stage is reached. During these years pain- 
less amputation of many of the joints may have 
occurred by a process of dry gangrene (Lepra mutilans). 
Erysipelas may occur. The nails and hair are shed. 
Sleeplessness may prove a distressing symptom. Loss 
of sexual power and sterility are manifest late in the 



LEPRA 413 

disease. There is a marked anesthesia of the soft 
palate, uvula, and pharynx. This form lasts much 
longer than the tubercular form, fifteen years being an 
average duration. Sometimes a fair degree of health 
is preserved for a much greater length of time. In most 
all cases more or less hebetude of mind is marked, be- 
coming more pronounced with the duration of the disease. 

The mixed form is a combination of the symptoms of 
the two former varieties, and perhaps is the one most 
commonly met with in this country. Indeed, it is the 
rule that all tubercular cases present certain symptoms 
of the anesthetic form, and vice versa, the variety being 
named from the prevailing lesion. 

Etiology. — Up to within a few years various agencies 
were regarded as causes of leprosy, such as residence by 
the seashore, eating of putrid fish, heredity; but in the 
light of our present knowledge there is but one cause, 
and that is contagion. The contagiousness of the disease 
is a strong plea for the segregation of the lepers within 
our own country. 

Leprosy is seen in both sexes, though the male sex is 
more often affected. It is rare in children, and is never 
seen in infants; a strong argument against heredity. Its 
incubation stage is very long, reaching over a period of 
years. It occurs in all countries and climates, but is 
endemic in certain regions. It seems that a damp, cold 
climate, or a hot, moist climate favors the disease. Spor- 
adic cases have been reported, but careful investigation 
would doubtless show that they had been exposed to 
contagion. Vaccination has been a carrier of contagion. 
It may gain entrance to the system, as through an 
abrasion of the skin, but its most common route is prob- 
ably through the nose and mouth. 

Pathology. — The bacillus lepra? is the cause of leprosy. 
This has been found in the skin, mucous membranes, 
the tubercles, the infiltrations, the lymphatic glands, 
nerves, spleen, liver, walls of the bloodvessels, hair 
follicles, and sebaceous glands. It was discovered bv 



414 DISEASES OF THE SKIN 

Hansen in 1874, and pure cultures of it made in 1909 
by Clegg and Duval. "This bacillus occurs as straight or 
very slightly curved rods, 5-0V0 °f an mcn m length, which 
may have knob-shaped expansions at their ends or in 
their length, due to the presence of two or five spores." 
(Crocker.) After gaining entrance to the tissue the 
bacilli lie in the lymph spaces and produce an infiltra- 
tion of round and spindle-shaped connective-tissue cells, 
lymphocytes, mast cells, and occasionally polynuclear 
leukocytes. As they multiply they form colonies united 
by zooglea, and plasma cells appear around the capillaries. 
A certain number become intracellular, and large char- 
acteristic cells containing vacuoles, nuclei and bacilli 
single or in clumps may be noted. These are lepra cells. 
The bacilli spread by the lymphatic and blood streams. 
The lepra nodule resembles, but is less vascular than 
ordinary granulation, tissue. The epidermis is not 
involved. Just below the epidermis are seen the largest 
tumor cells. The youngest and smallest cells are at the 
base of the nodule. In the upper layers are found the 
so-called "globi," accumulations of degenerated cells, 
sharply circumscribed, and densely packed with bacilli. 
Diagnosis. — In a fully developed case little difficulty 
in diagnosis can arise. Sometimes lepra will need to be 
differentiated from erythema multiforme; syphilis; lupus; 
morphea; vitiligo, and syringomyelia. The presence of 
anesthesia, the occurrence of lepra fever, and the enlarge- 
ment of the ulnar nerves in any doubtful case will establish 
the diagnosis of leprosy. Besides these, erythema runs a 
more acute course; syphilis of the tubercular form presents 
redder tubercles, which ulcerate more rapidly, are grouped, 
and a history of syphilis is usually attainable; the lupus 
tubercles are small, of apple-jelly color, soft, do not 
produce thickening of the eye-brows and nodular lobula- 
tion of the ears, and group themselves in patches in 
which cicatricial tissue will be found; morphea has a 
lardaceous appearance with a violaceous border; vitiligo 
patches are more lead-white and sharply defined, while 



LEPRA 415 

the skin is unaltered in texture and normal in sensation. 
Syringomyelia lacks the nerve enlargements, the lepra 
fever, and the multilations of leprosy. 

Treatment. — The best chance for recovery from 
leprosy is removal to a region where the disease is not 
endemic. This, with attention to hygiene, and a general 
tonic treatment, will do a great deal toward a cure. 
Qiiinin may be given during the febrile attacks. Of 
internal remedies, chaulmoogra oil holds the first rank, 
with an initial dose of 3 minims three times a day, and 
then gradually increased to as high a dose as the patient 
will stand. Nausea, vomiting, and diarrhea show when 
this is reached. It may be given in capsules. As this 
oil may cause fatty degeneration of the liver and kidneys 
if given over too long a period, it is well to interrupt its 
administration from time to time. Gynocardic acid has 
sometimes been substituted for it in doses of f grain 
(0.033) to 2 grains (0.2) t. i. d., the magnesium or sodium 
compound being used. G. H. Fox 1 has cured one patient 
by giving nux vomica or strychnin up to full constitutional 
effects, and then administering chaulmoogra oil continu- 
ously. Gurjun oil is also highly commended in an emul- 
sion of 1 part of the oil and 3 parts of lime-water, of which 
the dose is J ounce (16) morning and night. 

Unna claims to have cured one case with sulpho- 
ichthyolate of sodium from 6 (0.36) to 45 (3) grains a day, 
but others who have tried it have not had the same suc- 
cess. Salicylate of soda, 30 grains (2) every four hours 
until 2 drachms (8) are taken; salol in full doses; thymol, 
45 (3) to 60 (4) grains a day; carbolic acid up to 15 
grains (1) a day, are advocated by Lutz, Besnier, and 
others. H. R. Crocker 2 has had good results in one 
case by weekly and then semi-weekly hypodermic injec- 
tions of J of a grain of bichloride of mercury in 20 minims 
of oil. These were given for three months and then 

1 Post-Graduate, 1885-6, i, 143. 

2 Lancet, 1896, ii, 364. 



416 DISEASES OF THE SKIN 

intermitted for three months. Dyer 1 and Woolson 2 report 
good results from the use of antivenene. 

Externally the chaulmoogra or gurjun oil may be rubbed 
in daily, an emulsion of it being made with 1 to 3 parts 
of lime-water or olive oil. Mastin, a product of the 
cultivation of lepra bacilli on milk, is said to be useful 
in early cases. A solution of one part in 100 parts of 
hot sterilized olive oil is used, 0.5 c.c. is injected once a 
week, and later 1 c.c. 

The ulcers are to be treated upon the usual surgical 
principles. Unna 3 recommends rubbing into all the 
lesions, but those on the hands and face the following: 



I^ — Chrysarobin., 




Ichthyol., 


aa 3iss 


Ac. salicyl., 


gr. xl 


Ungt. simpl., 


ad §iv 



2 '5 
ad 128 I M. 

On the face and hands he substitutes pyrogallol for the 
chrysarobin. To counteract the bad effects of the drugs 
he administers 30 drops (2) of dilute hydrochloric acid 
during the day. For women and children he substitutes 
resorcin for the chrysarobin. To old nodes, after pro- 
tecting the surrounding skin, he applies during five to 
seven days a plaster mull containing 20 to 40 parts of 
salicylic acid and 40 parts of creosote. 

The so-called Bhau Daji treatment 4 is said to have pro- 
duced remarkable effects in from six to eight weeks after 
it was begun. It consists in the use of the oil of hydno- 
carpus inebrians, of which fromTfUO (0.66) togss (0.16) is 
taken in the morning in boiled milk. The patient is also 
anointed with the oil. Two hours afterward the oil is 
washed off in a warm bath. He is anointed again on going 
to bed. He is not allowed to eat pork, beef, or fish, nor 
to drink alcoholics, tea, or coffee. He is fed on milk, 
fruit, vegetables, butter, eggs, mutton, and fowls. Roake 5 

1 New Orleans Med. and Surg. Jour., Oct., 1897. 

2 Phila. Med. Jour., Dec. 23, 1899. 

8 Jour. Cutan. and Gen.-Urin. Dis., 1896, xiv., 413. 

* British Jour. Dermat., 1893, v, 203. 5 Ibid. 



LEUKOPLAKIA 417 

advocates excision of the tubercles, followed by the 
application of pure carbolic acid. The thermo- and electro- 
cautery may be used to the same end. X-rays seem to 
exert a curative effect on the lesions. Segregation is the 
only preventive measure. 

Prognosis. — The prognosis is bad, as the disease 
steadily progresses to a fatal termination unless the 
patient can be removed from the endemic region. If he 
can be removed, there is a chance of staying the disease. 
In some instances the disease, even when the patient does 
not change his residence, pauses in its course for a long 
time; but eventually it will again become active. 

Leukopathia Unguium or Leukonychia. — This affection 
consists in the appearance of white spots in the nail, 
which originate in the lunula, and gradually approach the 
free end of the nail as it grows forward. Sometimes these 
take the form of stripes or lines. Rarely the whole nail is 
affected. The nail substance is otherwise unaltered. The 
spots are thought to be due to air spaces in the nail sub- 
stance. M. L. Heidingsfeld 1 believes that they are due 
to a disturbance in the growth, development, or keratini- 
zation of the matrix cells in their change to nail struc- 
ture. Why these occur we do not know. Possibly there 
may be a process of fatty degeneration of the nerve cells 
and subsequent absorption of the fat (Taylor) . Or they 
may be caused by pressing back the nail fold in over- 
zealous manicuring. They are common in the young, 
and coincident with white spots in the teeth (Hutchin- 
son). They very often are noticed after fevers or other 
lowered conditions of health. Nothing can be done for 
this deformity except caring for the general health of the 
patient and stopping any bad habit. Arsenic might be 
tried. 

Leukoplakia. — This is an affection of the mucous mem- 
brane of the tongue, lips, inside of the cheeks, glans 

1 Jour. Cutan. and Gen.-Urin. Dis., 1900, xv, 490. 

27 



418 DISEASES OF THE SKIN 

penis and vulva, that has been described under the names 
psoriasis buccalis, ichthyosis linguae, leukokeratosis buc- 
calis, tylosis linguae, and smoker's patches. It occurs in 
the form of ivory-white or bluish-white, glistening, 
irregularly shaped patches upon the mucous membranes, 
that may be a little elevated. To the touch and tongue 
they feel rough. They may give rise to no discomfort, 
or they may interfere with chewing and speaking. They 
may be fissured or papillomatous. There is sometimes 
salivation. On the penis the disease appears as a circular 
band like infiltration with whitening and thickening 
of the mucous membrane. There is always danger of the 
development of carcinoma from them. They are caused 
by smoking, or occur in syphilis, psoriasis, lithemia, 
stomachic or intestinal catarrh, diabetes, and disturbed 
nervous influences. Rubbing of the tongue against the 
sharp edge of a decayed tooth sometimes seems to cause 
them. It is thought by some that syphilis is at the bottom 
of all of them, it affecting the tissues in such a way that 
the various irritants incite the disease. But cases occur 
in non-syphilitic subjects. Sometimes they arise without 
assignable cause. 

Diagnosis. — Leukoplakia differs from the mucous 
patch in its more chronic course and slight tendency to 
ulceration. Lichen planus, when occurring in the mouth, 
resembles the disease very strongly, but takes the form 
of rings, festoons, and disks, and the typical lichen 
papules can be found on the skin. 

Treatment. — It is very essential that tobacco be 
given up if the patient has been in the habit of using it. 
It is also necessary to address remedies to the cure or 
relief of any lithemic or digestive disorder; and to have 
the teeth put and kept in good order. The frequent 
use of normal salt solution as a mouth wash is advisable 
combined with the application of balsam of Peru 
daily or every other day. An antisyphilitic treatment 
may be tried. The hypodermic administration of 
mercury is far better that the administration of the 



LEUKEMIA CUTIS 419 

same drug by the mouth. Sometimes a patch may 
be removed by the daily application of pure lactic acid; 
or | per cent, solution of bichloride of mercury; or 10 to 
30 per cent, solution of salicylic acid; or 20 per cent, of 
chromic acid; or 2 to 10 per cent, of bichromate of potash; 
or by galvano- or actual cautery. S. Sherwell has had 
good success with the acid nitrate of mercury in 10 to 
50 per cent, strength, according to the intensity of the 
process. Great care must be had in its use, the surround- 
ing parts being protected by means of absorbent cotton, 
and an alkali held ready to neutralize any of the acid 
that has gone beyond the intended part, as well as to 
apply to the cauterized surface after a few moments. 
It is a very painful procedure. Hyde advocated the use 
of the dental burr after the injection of cocain. The 
use of the high-frequency spark is advocated by Con- 
stantin. 1 A 20 per cent, solution of cocain should be 
kept in contact with the place for two or three minutes. 
Healing is said to take place in two weeks. 

Prognosis. — It is a very obstinate disease. Patches 
not infrequently take on a cancerous change. 

Leukemia Cutis. — Leukemia is a disease characterized 
by a persistent increase of white-blood corpuscles associ- 
ated with changes in the lymphatic glands, bone marrow, 
and spleen. In this condition the skin is involved at 
times. The majority of cases occur in young people. 
The skin manifestations vary. In some cases there are 
eczematous patches, with much thickening of the skin, 
upon which tumors may or may not form. The patches 
do not yield readily to treatment directed to the cure 
of eczema, and the itching is intense. In other cases 
there is an eruption of tumors that are flat, slightly 
raised, yellowish or brownish red, from the size of a 
millet seed to that of a cherry. There may be only a 
few of them or there may be very many, and crowded 
together on a thickened skin so as to give the patch a 

1 Annal. derm, et syph., 1911, ii, 91. 



420 DISEASES OF THE SKIN 

tabulated appearance. Some of them may have a central 
depression. They seldom ulcerate. In any case there 
is a general enlargement of the lymphatic glands. In 
the tumor form the disease resembles granuloma fun- 
goides, but the tumors do not tend to ulcerate, the general 
enlargement of the lymphatic glands is pronounced, and 
the blood count is decisive. Eczema is more tractable 
to treatment, and is unattended by general lymphatic 
enlargement. The treatment is that of the underlying 
disease. 

Lichenification. — This is the neurodermite of the French. 

Symptoms. — The disease begins as an intermittent 
itching of the skin of a limited area; or more rarely as a 
chronic pruritus with paroxysmal crises. The itching is 
always intense. On account of the scratching to relieve 
the itching, changes take place in the skin by degrees. It 
becomes slightly reddened and assumes the appearance 
of shagreen leather, with here and there flattened, shiny 
papules somewhat like those of lichen planus. Gradually 
it takes on a brownish-red or pigmented color, becomes 
greatly thickened, infiltrated, and marked by ridges 
that cross each other at right angles. The patches so 
formed vary in size and shape. While commonly oval 
they may be triangular, semi-circular, or of other shape, 
such as band or linear. A fully developed patch has about 
it a zone of light brown or brownish-red color, which 
is slightly thickened, shades off into the surrounding 
skin, and has on it a lot of hypertrophied papilla? in 
rows that cross each other. The zone is wanting at 
times. Inside of this zone, or alone if it is wanting, the 
skin is greatly thickened, brownish or pigmented, marked 
by ridges that cross each other at right angles, and, 
usually scaly. The disease is essentially chronic, lasting, 
with intermissions, for years. If recovery occurs, the 
skin resumes its normal appearance. It is met with 
most often on the back of the neck, the upper and inner 
surface of the thighs, the loins, between the buttocks, 



LICHENIFICA TION 421 

the lower external part of the leg, the scrotum, labia 
rnajora, popliteal and axillary spaces, palms and soles. 
Cases of "chronic itching papular eruption of the axilW 
reported by G. H. Fox and others probably are of this 
class. 

Fig. 58 




Lichenification as seen in axilla. (M. Hassen.) 1 

Etiology. — The disease may be secondary to any 
itching skin disease, as eczema or psoriasis. It often 
develops of itself. It is more frequent in women than 
in men, and occurs almost always in neurotic subjects. 
The real cause is yet to be found. 

1 Jour. Araer. Med. Assoc, 1911, lvi, 194. 



422 DISEASES OF THE SKIN 

Diagnosis. — Chronic squamous eczema bears a strong 
resemblance to licheniflcation. The quadrillage of the 
skin, the chronic course of the disease often extending 
over years without change, and the absence of patches 
of acute or subacute eczema elsewhere, should differ- 
entiate licheniflcation. 

Treatment. — Attention should be given to the general 
condition of the patient, such drugs as phenacetin, 
aspirin, bromids, and perhaps arsenic being given. 
Locally the high-frequency current, .T-rays, or other form 
of electricity may relieve itching. Ointments and lotions 
containing tar, carbolic acid, ichthyol, resorcin, or other 
antipruritics should be used. 

Lichen Nitidus. — This is a rare disease of the skin 
judging by the small number of cases reported. As it 
gives rise to no inconvenience in most cases, it may 
be more common than is supposed. One of the best 
descriptions we have seen is by Arndt, 1 from which what 
follows is largely taken. 

Symptoms.: — The disease consists in an eruption of 
pinhead-sized, sharply rounded or polygonal, hemi- 
spherical or fiat papules, of the color of the surrounding 
skin, or pale red or yellowish brown. Most of them have 
a small depression in the centre. They are but slightly 
raised, and of nearly uniform size. They show no tendency 
to group, but sometimes occur in lines or aggregated 
patches in which the individual lesions do not coalesce. 
They may last for years, and then disappear without 
leaving a trace on the skin. Their site of predilection is 
the penis; less often they occur on the abdomen, especially 
about the umbilicus, and the flexor surface of the elbows 
and wrists. At times the eruption is widespread, when 
it is symmetrical. The palms, soles, and face are usually 
free. There are no subjective symptoms. All cases 
but one have been in males. 

1 Dermat. Zeit., 1909, xvi, 551. 



LICHEN OBTUSUS CORNEOUS 423 

Etiology and Pathology. — Nothing is known of the 
cause of the eruption. It is thought by some to be a 
tuberculide as the tissues have a tubercular makeup 
with epithelioid and giant cells. 

Diagnosis. — It differs from lichen planus in not 
itching, in its papules not enlarging, nor forming rings, 
and in the absence of the purple color. Flat warts are 
readily removed by the curette. Lichen scrofulosorum 
differs from it in being follicular and scaly. 

Treatment thus far has been unavailing. 

Lichen Obtusus Corneous. — C. J. White 1 following Brocq, 
who first described the disease, gives the symptoms of 
this rare malady as follows: 

The eruption consists in the appearance on the skin of 
a number of globular lesions, from 3 to 10 mm. in diam- 
eter, which are found most often on the upper and lower 
extremities, especially on the extensor surfaces. They 
begin as roundish, hemispherical papules, pinkish white 
in color, which slowly enlarge, and assume a brownish 
or rather deep cafe-au-lait tint. They are covered by a 
complete layer of fine, dry, grayish, very adherent scales, 
which become stratified, and later have a cornified appear- 
ance. The lesions are discrete and few, and develop with 
extreme slowness. The disease is very itchy, the patient 
scratching for relief until the horny tips of the papules 
are torn off. The lesions may present crater-form 
depressions, sometimes filled with' blood crusts. Some 
of the papules have horny plugs in them. Most all the 
cases have occurred in women. 

In White's case, the blood was found to coagulate in 
two minutes and fifty seconds, the normal time being one 
minute and forty-five seconds. The calcium contents 
was 1 to 600, the normal being 1 to 1500. 

White regards the disease as the same as that described 
by Hardaway as " Multiple tumors of the skin accom- 

1 Jour. Cutan. Dis., 1907, xxv, 385. 



424 DISEASES OF THE SKIN 

panied by intense pruritus": and by Schamberg and 
Hirschberg as "Multiple tumors of the skin in negroes 
associated with itching." It is probable that the "Noduli 
Cutanei" of Arning and Lewandowsky 1 belong to this 
class of lesions, as well as the "Porrigo Nodularis" of 
Hyde. Brocq was uncertain whether it was a form of 
lichen planus or a pure neurodermatitis, but was inclined 
to the later view. White's case improved under lactic 
acid internally, and chrysarobin externally. 

Lichen Pilaris. — This term is usually used as a synonym 
of keratosis pilaris. But Crocker describes it as a separate 
disease, the lichen spinulosus of Devergie. 

Symptoms. — It develops acutely or subacutely in crops. 
It consists in an eruption of pinhead-sized, red, conical 
papules, in the centre of which is a horny spine pro- 
jecting about j-q of a inch. These spines can be picked 
out, and leave a depression in the papule. After a time 
the redness subsides and the papule becomes the color 
of the skin. The papules are crowded together in patches, 
which are round, or large and irregular in outline. They 
occur in few or many regions and are symmetrically dis- 
tributed. The face, upper parts of chest, hands, and feet 
are usually exempt. They give a nutmeg-grater sensation 
to the hand when passed over the patches. There is 
little or no itching. 

Etiology. — Children are the chief subjects of the 
disease, boys more often than girls. 

Diagnosis. — It differs from keratosis pilaris in its 
spines, its inflammatory redness, acuteness of outbreak, 
and its patchy 'character. Lichen ruber acuminatus is 
marked on the backs of the hands, which are spared in 
lichen pilaris, and is scaly and lacks the spines. 

Treatment. — Alkaline baths and linimentum saponis 
well rubbed in will cure the disease. If there is much 
inflammation, it is best to use an oil instead of the soap 
liniment. 

1 Archiv Derm. u. Syph., 1911, ex, 3. 



LICHEN PLANUS 



425 



Lichen Planus. — A chronic disease of the skin charac- 
terized by an eruption of smooth, waxy, angular, umbili- 
cated, red papules, that tend to form scaly, lilac-colored, 
elevated, and infiltrated patches especially upon the flexor 
surfaces of the wrists and the inside of the knees. 

While the testimony from skilled observers is over- 
whelming that lichen planus papules may occur with 
lichen ruber, and while some cases of lichen ruber have 
developed after and together with lichen planus, still we 
see so many cases of the latter occurring by itself that 

Fig. 59 




Lichen planus. (Fox. 1 ) 

it merits a special description. In this country and in 
England lichen planus is far more frequent than is lichen 
ruber, and is regarded as a separate disease. 

Symptoms. — The disease begins as an eruption of small 
purplish- or crimson-red, angular, flat, slightly raised 
papules, varying in size from yg- to J of an inch in dia- 
meter. The surface of the papules is smooth and shiny, 
" waxy-looking," and they have a small depression in 
the centre. When fully developed the papules may have 



1 G. H. Fox: The Skin Diseases of Children, New York, 1897. 



426 



DISEASES OF THE SKIN 



on them delicate gray striations, which are characteristic 
of the disease. The papules may remain discrete, and be 
disseminated over a larger or smaller area; or they may 
arrange themselves in rows, or form rings, or aggregate 
themselves into patches, the single papules disappearing. 
The single papules are not scaly, the patches are slightly 
so. The patches may be small, and if so there is apt to 
be a well-marked depression in their centre, and their 
shape is round or oval. The larger patches have no 

Fig. 60 




Lichen planus. (Fox.) 



definite shape nor depression, but are well defined and 
elevated. Characteristic single papules will be found 
scattered about in the neighborhood of the patches. 
The color of the patches is characteristic, and may be 
defined as lilac. It is an important aid in diagnosis. 
The disease is very pruritic, and excoriations are often 
seen. Both the papules and patches on disappearing 
leave behind pigmented, slightly atrophic spots, which 
after a time, fade away. It is still a moot-point as to 
whether the individual papule enlarges peripherally or 



LICHEN PLANUS 427 

not. Like those of psoriasis, the papules of lichen planus 
may appear upon scratched surfaces. 

The disease is most often met with upon the anterior 
surface of the wrists and forearms, and upon the inside 
of the knees, the former being the favorite location. But 
it may occur anywhere, other favorite locations being the 
flanks, lower part of the abdomen, and of the legs, and 
it may involve a large part of the body, though it rarely 
becomes general. The glans penis is at times affected, 
sometimes before the disease is seen elsewhere. If the 
prepuce is long the papules will be white like on the 
mucous membrane of the lips. If the glans is uncovered, 
the color of the papules will be the same as on the skin. 
The eruption has also been seen on the vulva. On the 
palms and soles there may be red, slightly hyperkeratotic, 
papular elevations that become confluent, and form irreg- 
ular patches that may involve the whole palmar surface 
of the hands and fingers. The edge of the patches is 
sharply defined by a slightly raised border with, at times, 
a red zone on the outside. The palms feel like parch- 
ment and are of a brown color. When the nails are 
affected, they have on them either prominent elevations, 
like papules, forming vertical lines, or raised lines that 
run parallel to each other. The nails are rough, and at 
the free border of some nails there are corneous pads of 
brown color. The mucous membranes of the lips and 
mouth are affected, and the disease then appears as 
white spots difficult if not impossible of diagnosis without 
the occurrence of the typical eruption on the integument. 
The involvement of the mucous membranes is rarely 
reported. It is probably more common than is supposed, 
because the mouth is seldom inspected, as the lesions give 
rise to no discomfort. As a rule, there is more or less 
symmetry shown in the disposition of the efflorescences; 
and pruritus, which usually is marked. The general 
health is often unaffected, but, on the other hand, many 
of the subjects of the disease are not in perfect condition 
when the disease begins, and not a few others become 



428 DISEASES OF THE SKIN 

greatly broken down on account of the loss of sleep, and 
continual discomfort caused by the pruritus. The course 
of the disease is chronic, and new outbreaks are liable to 
occur. 

Fig. 61 



$ 






Lichen ruber moniliformis. (After Taylor.) 

Kaposi 1 has described a unique form of this disease 
under the name of lichen ruber moniliformis, in which the 
typical lesions became tranformed into keloidal nodes 
arranged in lines (Fig. 61). The nodes were in some 
places as large as cherries with their bases confluent and 
their upper parts separated by furrows. Unna 2 described 

1 Vierteljahr. f. Dermat. u. Syph., 1886, xiii, 571. 

2 St. Petersburg, med. Wochenschr., 1884, i, 447. 



LICHEN PLANUS 429 

under the name of lichen obtusus, a form of the disease in 
which the papules are midway between the acuminate and 
the plane. They are large and waxy, discrete, often 
convex, frequently bluish white, not scaly, and but 
slightly itchy. A lichen verrucosus and a lichen hyper- 
trophicus have also been described. These are seen 
most often on the lower parts of the legs and do not look 
at all like the usual eruption. They are elevated, warty, 
firm, violaceous, in irregularly shaped patches of various 
sizes. The gray striations are usually well marked on 
them. This form is specially obstinate to treatment. 
Hallopeau and others have reported cases in which angular 
flat papules of white color occur, under the name of 
lichen planus atrophicus seu sclerosus seu morpheicus. 
It is met with on the upper part of the chest and arms. 
White papules are seen in colored races. Lichen planus 
striatus occurs as a long band, usually upon the inside 
of the thigh, sometimes extending the entire length of 
the limb. 

Pemphigoid eruptions occasionally occur as part of 
the disease. Crocker, who at one time described an 
infantile form of the disease in which the papules come 
out acutely in groups, acuminate at first, but soon 
becoming flat, angular, and red, changing to purple, 
now regards it as merely a miliaria rubra. 

Etiology. — We know no more about the causes of 
lichen planus that we do about those of lichen ruber. A 
neurotic element is marked in many of the cases, and 
cases have been reported in which the papules were dis- 
tributed along the course of a nerve. 1 Nervous exhaus- 
tion, rheumatic sweating, and checking perspiration are 
given as causes. Its subjects are mostly adults, many 
of them otherwise in good health. Many are careworn 
or worried. It does occur in children. It is probable 
that a toxemia of some sort, probably derived from the 
intestinal tract, is the foundation of the disease. It is 

1 Mackenzie: British Med. Jour., 1884, ii, 1077. 



430 DISEASES OF THE SKIN 

more frequent in women than in men in this country 
and in England, though in Austria the reverse obtains. 

Pathology. — According to Fordyce 1 the disease begins 
by a dilatation of the bloodvessels and lymph spaces of 
the papillae of the skin, causing , a proliferation of the 
connective-tissue cells, the papillae becoming swollen 
and reddened. At the same time or soon after there is 
a round-celled infiltration in the subpapillary layer. The 
lymph spaces are enormously dilated, the tissues become 
edematous, an intra- and inter-cellular edema making 
its appearance in the epidermis. Later the rete pegs 
and the middle layer of the rete flatten, the cells assume 
more of a spindle shape, and the granular and horny 
layers hypertrophy. This increases especially in the lower 
part of the central part of the papule, where it sinks in 
at the expense of the rete and forms a small horny plug, 
producing the umbilication. Subepidermic vesicles fre- 
quently form, probably due to a serous exudation on 
account of a lowering of the resistance of the epidermis. 
The appendages of the skin are unaltered. The gray 
striae are due to the thickening of the granular layer. 

Diagnosis. — An eruption of flat, shiny, angular, 
umbilicated papules of a lilac color showing grayish 
striations situated on the anterior surfaces of the wrists 
can be nothing but lichen planus. The same character- 
istics are diagnostic anywhere on the body, and sufficient 
to distinguish the disease from eczema and psoriasis. 
Moreover, eczema will show a tendency to moisture, or 
the papules will undergo change; and psoriasis will be 
almost sure to have characteristic patches upon the 
elbows and knees, covered with more abundant white and 
ofttimes thick scales. Syphilis sometimes bears a strong 
resemblance to lichen planus, but itching is less marked, 
its eruption is more polymorphous, and its color is more 
that of raw ham. 

Treatment. — In the treatment of lichen planus, nerve 
tonics or sedatives and attention to the general health 

1 Jour. Cutan. Dis., 1910, xxviii, 57. 



LICHEN PLANUS 431 

as well as to the hygiene both- of the body and mind, 
are our most reliable agents. Arsenic is useful in some 
cases. Polland 1 advises salvarsan intravenously injected. 
Morris speaks highly of biniodide of mercury in the initial 
dose of yV °f a grain, which is to be gradually increased. 
The protiodide of mercury, i to i of a grain three times 
a day, is useful in many cases. Antipyrin, phenacetin, 
and the spinal douche render good service. Alkaline 
diuretics sometimes do well, such as the acetate of potash. 
Boeck and R. W. Taylor speak well of 15-grain (1) doses 
of chlorate of potash fifteen minutes after eating, followed 
in a quarter of an hour by 20 drops (1 .33) of dilute nitric 
acid in a wineglassful of water. Crocker speaks highly of 
salicin, 15 to 20 grains (1 to 1.33) three times a day, 
and of quinin. Salicylate of soda or salol often acts well. 
In obstinate cases change of scene in travel often cures 
when other measures fail. 

Locally, stimulants, such as tar, pyrogallol, and chrys- 
arobin, will prove serviceable. Stelwagon says that 
liquor carbonis detergens is the most efficient application. 
It is to be used at first diluted with 10 to 15 parts of 
water. If well borne the strength should be increased 
until it is used pure. It is to be dabbed on twice or 
more often daily. It may be used as an ointment of 10 
to 15 per cent, strength. Unnas ointment, as given 
under lichen ruber acuminatus, is widely used. Touch- 
ing the papules with pure carbolic acid may be tried. 
In acute cases alkalin lotions such as calamin lotion 
with carbolic acid will allay irritation. Thymol and 
naphtol may be tried as in lichen acuminatus. In 
chronic cases Hardaway recommends: 



-Saponis olivse praep., 


5iv 




120 


Olei rusci, 








Glycerini, 


aa gj 


aa 


32 


01. rosmarini, 


3iss 




6 


Alcoholis, 


ad gviij 


ad 


250 



M. 

well rubbed in w T ith a piece of flannel. The patches are 
sometimes favorably affected by mercurial plaster. 

1 Dermat. Zeit., 1913, xx, 778. 



432 DISEASES OF THE SKIN 

Some cases in which the skin is very irritable are best 
treated by means of prolonged simple or medicated 
emollient baths, followed by some ointment such as 
vaselin or eucerin. In the hypertrophic form salicylic 
acid plaster is useful. The patches may be curetted 
out. The x-rays also remove them. Pusey advises 
that they be used on alternate days, or less frequently, 
care being taken to avoid dermatitis. In generalized 
cases they relieve the pruritus, as also does the high- 
frequency current. 

Prognosis. — The prognosis is generally favorable, 
though the disease is often very obstinate. Relapses 
are not infrequent. 

Lichen Planus Sclerosus et Atrophicus of Hallopeau. 1 
Symptoms. — -The sites of predilection of this disease 
are the upper part of the trunk, about the breasts, over 
the clavicles extending over the shoulders and down 
over the upper part of the back, the neck, axillse, and 
forearms; also at times on the abdomen, thighs, vulva, 
buccal mucous membrane, vaginal mucous membrane, 
and, in one case, on the temple. The eruption consists 
in irregular, often polygonal, flat-topped, white papules. 
Some of the papules may be conical. The color is ivory 
or mother-of-pearl, sometimes with a yellowish tinge. 
The papules are firm to the touch and when in groups 
they may be wrinkled on top. Occasionally a rosy or 
slightly pigmented zone surrounds them. They may be 
grouped or discrete. If grouped in patches, one or more 
black or dark horny plugs, or minute pits will be seen 
on the shiny surface. The patches may be several 
centimeters in diameter, or linear. They are persistent, 
but after a time undergo involution, and leave smooth, 
white, atrophic areas. Usually there is moderate itching. 
Diagnosis.- — It differs from lichen planus in having 
white instead of red papules, and in being less pruritic. It 

1 O. S. Ormsby: Jour. Amer. Med. Assoc, 1910, c, 901. 






LICHEN SCROFULOSORUM 433 

differs from circumscribed scleroderma in having papules, 
and horny plugs or pits. 

Treatment is along the same lines as lichen planus. 

Lichen Ruber Acuminatus. — The general voice of au- 
thority declares that this disease is the same as pityriasis 
rubra pilaris, and to the latter the reader is referred. 

Lichen Scrofulosorum or Scrofulosus. — A disease of the 
skin occurring in strumous subjects, consisting in an erup- 
tion of small pale papules that tend to group in round or 
half-moon-shaped figures upon the abdomen, sides of the 
chest, and flanks. It is one of the so-called tubercu- 
lides. 

Symptoms. — It occurs in the form of pinpoint- to 
pinhead-sized, grouped, conical papules, which may be 
of the color of the skin, or pale red or fawn colored. 
These papules occur around the hair follicles and form 
small round groups, or circles or segments of circles, upon 
the abdomen, sides of the chest, flanks, and neck in 
adults; and upon the extremities in children. They are 
somewhat scaly, but give rise to no inconvenience, so 
that they are often overlooked. In some cases the pap- 
ules are so numerous that the groups lose their distinctive 
shape, and large surfaces are covered, giving the skin a 
dirty-brown color. Many disseminated and discrete pap- 
ules are scattered over the body outside of the patches. 
Acne pustules may form; and a brown pigmentation of 
the face has been observed in some cases. The papules 
finally undergo absorption, desquamate, and leave transi- 
tory yellowish pigmentation. The disease runs a chronic 
slow course. Eczema may complicate matters. Kera- 
tosis pilaris is frequently well marked upon the limbs. 

Etiology. — The great majority of the subjects of this 
disease present evidences of tuberculosis and many, 
if not most, react to the tuberculin tests. A few are 
robust. The disease is most common in childhood, and 
is very uncommon after the twenty-fifth year of life. It 
is thought by many authorities to be a tubercular disease, 
28 



434 DISEASES OF THE SKIN 

due to the toxins of tuberculosis. Tubercle bacilli are 
not found in the papules. 

Pathology.— The papule is composed of lymphoid, 
epithelioid, and giant cells, infiltrating the papillae about 
the follicular opening, or the tissue about the vessels, hair 
follicles, and sebaceous glands. Semiglobular masses in 
the horny layer of the epidermis, and around the hair 
follicles, have been described. 1 

Diagnosis. — The disease must be differentiated from 
papular eczema, the papular syphilid, lichen ruber, a 
punctate psoriasis, and keratosis pilaris. Eczema differs 
from it in greater itching, in the brightness and rapid 
development of the papules, and in its tendency to vesic- 
ulation or moisture. The papular syphilid is of darker 
red color, much larger, and more polymorphous; the 
patient's age is usually greater, and the history and course 
of the eruption will soon decide the diagnosis. Lichen 
ruber has darker papules, which do not group in circles 
and segments of circles; they itch, and tend to involve 
the whole surface. The patients are more often adults, 
and there is a profound constitutional disturbance. Pso- 
riasis itches, is abundantly scaly, and its papules soon 
enlarge and form characteristic patches. Keratosis 
pilaris affects the extensor surfaces of the limbs by pre- 
ference, each papule is plainly about a hair, and the 
papules do not group. A curled-up hair will often be 
found in the centre of the papule. The absence of spines 
in the papules distinguishes it from Crocker's lichen 
pilaris. 

Treatment. — The persistent use of cod-liver oil both 
internally and externally will cure the disease. The 
syrup of the iodide of iron or the iodide of starch may be 
given with the oil. Good hygiene and food are valuable 
adjuncts. For the cod-liver oil, which is disagreeable 
for external use, other oil, such as cocoa-butter, may be 
used ; or vaselin with or without oil of cade. Crocker 

1 Gilchrist: Johns Hopkins Hosp. Bull., 1S89, page 84. 



LUPUS ERYTHEMATOSUS . 435 

recommends the addition of liq. plumb, subacetatis, Tflxv, 
(1) or thymol, 5 grains (0.33) to the ounce (32) of vaselin. 
The disease tends to get well of itself. 

Lichen Simplex. — See Papular eczema. 
Lichen Tropicus. — See Miliaria. 
Lipoma is a fatty tumor. 
Lues. — See Syphilis. 

Lupus Erythematosus. — Synonyms: Seborrhea conges- 
tiva; Lupus superficial ; Lupus sebaceous; Lupus ery- 
thematodes; Scrofulide erythemateuse or Ery theme 
centrifuge (Fr.); Dermatitis glandularis erythematosa 
(Morison) ; Ulerythema centrifigum (Unna) . 

This is a chronic disease of the skin, occurring in vari- 
ously sized, slightly elevated, scaly, red patches which 
show a strong tendency to the production of atrophic 
scars. 

Symptoms. — There are two varieties commonly de- 
scribed, namely, the circumscribed or discoid, and the 
diffuse, or disseminated, or aggregated. To these some 
of the English writers add a third, the telangiectic. 

The circumscribed or discoid form is the one most often 
met with. It occurs generally on the face, especially 
upon the sides of the nose and cheeks, the scalp, and 
the ears; more rarely upon the hands and feet; and still 
more rarely on other parts of the body. It begins by 
the appearance of several isolated or grouped red spots 
slightly elevated, of pinhead to split-pea size, with a thin 
adherent scale upon them. Some of these spots may be 
depressed in the centre. When the scale is removed there 
will be found upon its under side a delicate projection 
formed by a plug of sebaceous matter that dipped down 
into the mouth of the sebaceous gland. The mouth of 
the gland will be found patulous. These spots increase 
in size by peripheral extension to form disk-shaped figures 
of varying size; neighboring ones will coalesce, and thus 
patches will be formed, also covered with the fine grayish 
or white adherent scales. Now when the scale is raised 



436 



DISEASES OF THE SKIN 



a number of the characteristic prolongations will be 
found on its lower side. The margins of the patches 
are slightly raised, but the middle parts undergo in- 
volution, are lower than the margins, and after a time 



Fig. 62 








9*mm' :: ] 


•<."■■' if ~'- : - : ' , ■-: 








dfcV " 




►\ 



Lupus erythematosus. 1 

are apt to become cicatricial, the skin being atrophied. 
The scar-tissue thus formed is thin, delicate, and white, 
never puckered or deforming. 

The color of the patches is red, but of a peculiar hue 



By courtesy of Dr. S. Dana Hubbard. 



LUPUS ERYTHEMATOSUS 437 

that is characteristic, and perhaps can be best defined as 
violaceous. There is never any moisture connected with 
the disease. Burning or itching may or may not be pres- 
sent. The patches are of indefinite duration — months or 
years. At times they disappear of themselves, and do not 
leave scars, but the rule is that scars are left. The extent 
of the disease varies greatly, as well as the shape of the 
patches. The greater part of the face may be involved, 
or there may be only a single patch. Usually the eruption 
is symmetrical. A characteristic location for the disease 
is upon the back and sides of the nose and the contiguous 
parts of the cheeks, forming what has been fancifully 
called a butterfly, the ridge of the nose representing 
its body, and the cheeks its wings. Sometimes gyrate 
figures are formed. If the lobes of the ears are affec- 
ted they may at first resemble erythema pernio, but 
later become shrunken. When the fingers and toes are 
affected they present the appearance of chilblains, a per- 
sistent erythema; but when involution takes place there 
is left an atrophic condition. It may also appear on 
the hands and feet in the same way that it does on the 
face. The mucous membranes and the vermilion border 
of the lips may be affected, presenting patches with 
punctate excoriations of red color, or spotted with grayish 
masses of exudation and superficial cicatrices. The lips 
sometimes appear as if painted with collodion that is 
peeling off. Occurring upon the scalp it leads to per- 
manent loss of hair from well-defined patches, and the 
same may be said of it as it occurs on other hairy parts. 
The affected areas are not only bald, but converted into 
thin cicatricial tissue, at first red, later white. The 
disease may become stationary after a time. Relapses 
are liable to occur. The general health is unaffected. 

The diffuse or disseminate form is a more acute process, 
and exceedingly rare in this country. The disease usually 
begins on the face, and the limbs are involved before the 
trunk. It may follow the ordinary form of the disease, 
or appear suddenly, or slowly develop. The patches are 



438 DISEASES OF THE SKIN 

from pinhead to finger-nail size, slightly elevated, reddish 
brown, hyperemic, and hard; they pale under pressure, 
and are attended with heat and burning. In this stage 
they resemble erythema exudativum or the papular stage 
of eczema. There may be from twenty to a hundred or 
more of them crowded together upon the face and scat- 
tered over the body. Many of them may disappear in a 
few days without leaving any trace, while others will 
remain and become characteristic patches of lupus erythe- 
matosus with depressed cicatrices. The individual lesions 
do not increase in size, and the patches are formed by 
aggregations of single lesions. The eruption may be 
accompanied by a high degree of inflammation, exuda- 
tion, and crusting, or even by bullse. There may be deep, 
painful subcutaneous tumors in the joints, and glands at 
first, over which characteristic patches will form. In 
some acute cases the development of the patches is 
accompanied by fever, osteocopic pains and nocturnal 
headaches, and in some cases the patient will pass into a 
typhoid condition and die of some lung complication. 
Or there may be a persistent inflammation of the face, 
erysipelas per starts, which may lead through a typhoid 
state to death. There may be also swelling of the parotid 
glands and of various lymphatic glands. In some cases 
the disease bears a close resemblance to chilblain. 

The telangiectic form occurs, according to Crocker, as a 
persistent circumscribed redness, which close inspection 
shows to be due to dilated vessels. It is commonly 
located symmetrically upon the cheeks. Upon pinching 
up the skin it will be found to be markedly thickened. 
Some few comedones may be present. There is no 
desquamation. It runs a chronic course. 

Crocker also describes a nodular form in which round 
or oval, convex, distinctly raised nodules appear, which 
are brownish-red in color. They vary in size from a 
hemp-seed to a small bean. They occur upon the face 
most often, but may occur elsewhere. They may undergo 
involution. 



LUPUS ERYTHEMATOSUS 439 

Etiology. — About two-thirds of the cases occur in 
women. It seldom occurs before puberty, and most of 
the cases are under thirty years of age, though Kaposi 
has seen a case in a child of three years. Beyond these 
facts we know but little of its etiology. The French 
regard it as a scrofulous affection which, in the light of 
modern pathology, is regarded as tuberclar. While 
nothing suggesting its relation to a tuberculous process 
has ever been found in the skin, still, as not a few patients 
show other symptoms of a general tuberculosis, such as 
swollen or broken-down glands in the neck or cicatrices 
from the same, or give a history of tuberculosis in other 
members of their family, there is a growing opinion that 
the disease is a species of tuberculosis of the skin due to 
the toxins of that disease. The disseminated form is 
more often related to tuberculosis than is the discoid form. 
Crocker suggests a feeble circulation and prolonged expo- 
sure to great cold or heat as possible causes. It has been 
seen to follow upon frost-bite and sunburn. It would 
also seem that those who are subjects of seborrhea are 
predisposed to the disease. 

Pathology. — In spite of much careful study the 
exact pathology of the disease is still undetermined. J. A. 
Fordyce and 0. H. Holder 1 believe that the process is due 
to embolism of the small arteries, arising either on account 
of an alteration in the blood due to a toxin, or to some 
change in the walls of the vessels, or to a thrombus 
brought from some distant part. In the majority of cases 
the earliest manifestations of the disease are capillary 
obstruction and then an infiltration of round cells in the 
middle of the lower zone of the corium, the sebaceous 
glands and hair follicles being secondarily involved. The 
cicatricial scarring is the result of atrophic processes. 
Robinson 2 regards the disease as a local infectious pro- 
cess, a granuloma, inflammatory in character. This view 
is held also by Schoonheid. 3 

1 Med. Rec, 1900, lviii, 41. 

2 Trans. Amer. Dermat. Assoc, 1898, p. 70. 

3 Arch. f. Dermat. u. Syph., 1900, liv, 163. 



440 DISEASES OF THE SKIN 

Diagnosis. — The disease must be differentiated from 
lupus vulgaris, eczema, rosacea, psoriasis, and syphilis, 
A typical case occurring upon the face in the form of red 
patches, with fine cicatrices in the centre, and covered 
with a delicate white or grayish adherent scale, from the 
under side of which are a number of projections, offers no 
difficulty in diagnosis. Lupus vulgaris differs from lupus 
erythematosus in occurring before puberty, in showing 
no disposition to symmetry, in the presence of apple-jelly 
tubercles, in being a deep-seated disease, and in leading 
to far more disfiguring cicatrices. Eczema never leaves 
scars, is prone to exudation, itches, its scales do not show 
prolongations from the under side, and its patches 
undergo more rapid and varied changes. Psoriasis will 
be pretty sure to show characteristic patches covered 
with thick scales, and never causes scarring or leads to 
permanent loss of hair. Rosacea is largely composed of 
dilated bloodvessels, occupies the middle third of the 
face, often presents superficial pustules, does not leave 
scars, and is subject to frequent exacerbations. In 
syphilis a history of other lesions will be obtainable, there 
will be more evident infiltration, and the course of the 
lesions will be more rapid. The disseminate form of the 
disease is very difficult of diagnosis at first, but as soon 
as characteristic patches form the difficulty is removed. 

When lupus erythematosus occurs upon the scalp it 
causes a bald spot that may be mistaken for alopecia 
areata, but differs from it in its irregular shape, in the 
signs of inflammation in it, and in the cicatricial condi- 
tion of the scalp it leaves. Folliculitis decahans often 
shows inflamed follicles about the bald patch, lacks the 
comedones often seen in lupus erythematosus, frequently 
has tufts of hair in the patches, and has an irregular 
indented edge. A microscopic examination of the 
hairs from about a patch will decide as between lupus 
erythematosis and favus or ringworm. 

Treatment. — Little beyond the care of the general 
condition of the patient upon general principles can be 



LUPUS ERYTHEMATOSUS 441 

done for lupus erythematosus in the way of internal 
medication. McCall Anderson advocated the use of 
iodide of starch, made by triturating 24 grains of iodin 
with a little water, and gradually adding 1 ounce of 
starch, rubbing them well together until the mass becomes 
deep blue in color. Of this a heaped teaspoonful, increased 
gradually, may be given three times a day in water or 
gruel. Iodide of potassium, is also commended, as are 'phos- 
phorus and salicylate of soda. Crocker speaks well of 
salicin in 15-grain (1) doses three times a day, increased 
to 20 (1 .33) or 30 (2) grains. It is especially useful in acute 
cases. Whitehouse 1 has had good results from iodoform, 1 
grain, t.i.d., after meals. Quinin given in increasing doses 
seems to exert an influence on the disease when the patient 
can tolerate large doses. Hallander commends it in com- 
bination with painting the patch with tincture of iodin 
after washing it with absolute alcohol followed by ether. 
His dose is 7J grains (0.5) of quinin from two to eight 
times a day, the number of doses being gradually increased. 
When the patch begins to fade the number of doses is 
to be gradually reduced. Few can carry such amounts. 
If cinchonism develops the drug is to be stopped until it 
subsides, and then begun again. 

Local Treatment. — Sometimes in the early stages 
alkaline washes, such as lotions of zinc or lead, may be 
used. Or one composed of 



i — Zinci sulphat., 








Potassii sulphurat., 


aa 5 J 


aa 


4 


Alcohol, 


5iij 




12 


Aquae rosse, 


ad § iv 


ad 


128 



M. 

as in acne and rosacea. Green soap or prepared olive 
soap, or its tincture, may be used in more chronic cases. 
This is often serviceable for the disease as it attacks the 
eyelids. The affected parts are to be well rubbed with it, 
using a piece of flannel. The process is to be repeated 
every few days. If the reaction is too great, a little oil 

1 New York Med. Jour., 1899, lxix, 159. 



442 DISEASES OF THE SKIN 

or a glycerin lotion may be applied. Crocker advocates 
the addition of 1 or 2 drams (4 to 8) of the oil of cade to 
the ounce (32) of the tincture of green soap. Carbolic acid, 
pure, applied to the patches, as first advised by G. H. 
Fox, often acts admirably. It turns them white at first. 
Caution is necessary at first, only a small patch being 
painted with it. If used on a large patch it may cause 
the patient to faint. The application is to be repeated as 
soon as the crust falls. Fowler's solution 3 j (4) in distilled 
water g j (32) and spirits of chloroform 2 drops, applied 
externally in the morning and evening, is sometimes 
efficacious. Resorcin, 50 per cent, aqueous solution, 
applied once or twice a day until decided reaction takes 
place, and then cold cream or calamin lotion used until 
the reaction subsides, is a good plan of treatment. The 
resorcin solution must be repeated when the reaction has 
subsided. Pyrogallol, 10 per cent, in ointment, sometimes 
does well. N. Walker thinks that oxidized pyrogallol, 
1 to 2 per cent, in acetone collodion, is the best means 
we have; while others consider a combination of 10 per 
cent, pyrogallol with 40 per cent, of salicylic acid in 
collodion is better than anything else. Trichloracetic 
acid, in full strength so as to whiten the skin; oil of cade; 
solution of naphtol, 1 per cent.; tincture of iodin or 
iodide of glycerin; caustic potash, 1 part to 6 or 12 of water, 
have their advocates. Hydronaphtol plaster, resorcin 
plaster of 10 to 20 per cent, strength, and mercurial 
plaster are often excellent when persisted in. Sulphur 
or ichthyol in ointment or paste does well in some cases. 
Thilanin sometimes does well. H. Hebra has introduced 
the method of sopping the patches every fifteen minutes 
with pure alcohol containing 4 per cent, of menthol. 
Liquid air, or the snow from carbon dioxide, acts like 
caustics in these cases and sometimes gives most brilliant 
results. The part is frozen with it for from sixty to 
ninety seconds. This is one of the best methods of treat- 
ment. Both the Finsen light, the Kromayer lamp, and 
x-rays have cured many cases. The first gives the best 



LUPUS ERYTHEMATOSUS 443 

results — though they are attained slowly — and do not 
make the disease worse. It is not so useful in the chronic, 
thickened, deep-seated patches, as in the more superficial 
form. In some cases x-rays aggravate the disease. The 
high-frequency current, applied by means of vacuum glass 
tubes or a carbon point from three to ten minutes, has 
cured some superficial cases. The tube should be held 
a short distance from the skin so as to cause a bombard- 
ment of it by the sparks, and the strength of the current 
used should be such as to be short of causing severe pain. 
Stelwagon advises using it for from three to ten minutes, 
and repeating in from five to ten days. All cases should 
be carefully watched that the reaction from our remedies 
does not go too far. If the remedy produces too much 
reaction, it must be stopped, a mild zinc lotion applied 
until the irritation subsides, and then the remedy is to 
be used again. 

If these superficial caustics do not cure, resort may be 
had to linear scarifications, making a series of cross- 
hatchings, taking care not to go very deep. The bleeding 
is to be checked by pressure and the application of car- 
bolic acid, 2 drachms (8) to the ounce (32). Limited sur- 
faces must be taken at a time. Electrolysis by means of 
multiple punctures will sometimes give brilliant results. 
Sometimes running the needle across the patch, making 
a number of parallel insertions, will have a good effect. 
Evasion with a curette, galvano- or Paquelin cautery and 
strong escharotics, such as the acid nitrate of mercury, 
may have to be used in very obstinate cases, but not till 
all other means are exhausted, as they are apt to leave 
deep scars. 

Prognosis. — The prognosis should be guarded, as the 
disease is a most obstinate one, and prone to relapses. 
Though it may persist for many years there is a tendency 
to recovery as the disease is seldom seen in old people. A 
cure may, however, be affected by patient perseverance. 
It is wise always to tell our patients that scars are liable 
to be left, not only by the treatment employed, but by the 



444 DISEASES OF THE SKIN 

disease itself. An accidental attack of facial erysipelas 
cured one case under my observation. Epithelioma may 
develop on the cicatrix of a patch. The discoid form has 
little effect upon the health of the patient, but the dis- 
seminated variety not infrequently ends fatally. 

Lupus Pernio. — This disease affects the uncovered parts, 
hands, face, and especially the ears, nose, and upper lip. 
It is ill-defined, and extends over large surfaces. It is 
marked by cyanosis, telangiectasis, infiltration of the skin, 
diffuse tumefaction, Assuring of the skin, and superficial 
vesiculation. Slight ulcerations form that become cov- 
ered with crusts and last a long time. The old patches 
are studded with irregular cicatrices. It is a chronic dis- 
ease with no subjective symptoms. It occurs in lymphatic 
subjects. Its exact place has not been determined, 
some authorities regarding it as a form of lupus ery- 
thematosus, others as belonging to lupus vulgaris, while 
still others regard it as a chronic, infective granuloma. 

Lupus Vulgaris. — Synonyms: Noli me tangere; Herpes 
esthiomenes; (Fr.) Dartre rongeante, Scrofulide tuber- 
culeuse, Esthiomene; (Ger.) Fressende Flechte. 

This is a chronic neoplastic disease of the skin due to 
its invasion by the tubercle bacillus, and characterized 
by one or more brownish-red papules, tubercles, or 
infiltrated patches, that tend either to absorption or 
ulceration, and always leave scars. 

Symptoms. — Lupus vulgaris usually begins in child- 
hood and upon the face; the cheek and nose being the 
parts most usually affected. The initial lesion is a dark- 
red or brown pinpoint- to pinhead-sized papule, which 
may be on a level with the skin, depressed below, or 
raised above it. It is a tubercle in an anatomical sense. 
When it is punctured by a blunt instrument it is felt to 
be soft, readily being entered. There may be but a single 
lesion, but usually there are a few of them either grouped 
or scattered. After a time slightly scaly patches will form 
by the coalescence of the lesions which have enlarged into 



LUPUS VULGARIS 



445 



brownish-red, semi-translucent, smooth, shiny tubercles, 
or by the development of new lesions between the old ones. 
The shape of the patches is irregular. Rarely are they 
ring-shaped. The size of the patches varies greatly, but 
they are always elevated above the surface of the skin, of 
a dark-red color, and studded with the little brownish-red 
papules, so-called tubercles. The appearance of these 
tubercles has been likened by Hutchinson to that of apple- 
jelly. About the patch there may spring up new tuber- 
cles in the sound skin. There may be but one patch, or 
the whole face may be more or less covered with a num- 

Fig. 63 




A case of lupus vulgaris. 1 

ber of them. Symmetry is not a feature of the disease, 
often only one side of the face being affected. Sometimes 
two or more patches will coalesce at their borders, their 
centres will fade out, or rather become atrophic, and a 
gyrate patch will form, creeping over the skin with a 
well-marked, elevated, dark-red border. The centre of 
all the patches is lower than the border, and eventually 
is atrophic. 

The course of the disease is slow and chronic, and 
the fate of the patches varies greatly. For months 
or years they may remain absolutely quiet, and then 



Courtesy of Dr. H. Fox. 



446 DISEASES OF THE SKIN 

show signs of activity by new lesions appearing about 
the edges of the patches or in the scar tissue. This 
recrudescence in the scar is a characteristic of the dis- 
ease. The patches may entirely disappear, leaving a fine 
smooth cicatrix; this is rare without treatment. Or they 
may break down and form ulcers, which are irregularly 
rounded, shallow, with easily bleeding floors, and a 
moderate amount of purulent secretion that dries into a 
crust. This is the so-called lupus exulcerans, and is not 
very frequent in this country according to my experience. 
Sometimes upon this ulcerated surface papillary or warty 
growths will spring up, the so-called lupus papillomatosus 
or verrucosus. Sometimes the infiltration of the patch is 
unusually great, and then we have lupus hypertrophicus. 
Most commonly we have a non-ulcerated, exceedingly 
chronic infiltrated patch with areas of cicatricial tissue 
scattered through it. When the disease attacks the end 
of the nose, the whole of the soft parts is involved, and it 
will cause it to shrink up and convert it into cicatricial 
tissue. When the ear is diseased, it also shrinks up so as 
to be half the size it was originally. These changes are 
due either to ulceration or to the gradual absorption of 
the lupus tubercles. 

While the face is the site of predilection of lupus, it 
may also occur upon any part of the skin of the body, as 
well as upon the mucous membranes. In this latter 
situation it is most often secondary to the disease else- 
where; still it is often primary. Thus Bender 1 found 
that 30 T 3 o- per cent, of all his lupus cases began in the 
nasal mucous membrane. Pontoppidan also found the 
origin of the disease to be the nasal mucous membrane 
in many cases. In the nose it frequently leads to per- 
foration of the septum, and sometimes causes great 
deformity of the nose, but it does not attack the bones. 
All other mucous membranes may be attacked, the 
rectum and vagina being least often affected. Upon 

1 Vierteljahr. f. Derm. u. Syph., 1888, xv, 891. 



LUPUS VULGARIS 447 

mucous membranes we do not see the same tubercles as 
on the skin, but papillary excrescences which form patches. 
They may be absorbed or ulcerate. The conjunctivae 
may be involved primarily or secondarily. Epithelial 
cancer has developed in very rare instances upon the 
lupoid tissue itself, more commonly upon the scar tissue 
left by the lupus. Whenever it develops as a sequela 
of lupus its course is more rapid and its prognosis far 
more grave than is usually the case. Erysipelas is a not 
infrequent complication of lupus, and is sometimes 
curative in its action. Lupus of the extremities is often 
followed by permanent deformities and disabilities, and 
sometimes by tubercular lymphangitis. Implications of 
the lymphatic glands is exceptional in lupus, and then 
only in advanced cases. 

Under the names of lupus follicularis disseminatus and 
lupus miliaris have been described unusual cases of tuber- 
culosis of the skin that are seen mostly in young people 
in a rather acute form, reaching their full development in 
a few weeks or months. It affects especially the forehead 
and cheeks, upper extremities, and back. The eruption 
consists in large and small nodules infiltrating the whole 
thickness of the skin. On a number of them are seen 
miliary brownish nodules partly in groups, partly dis- 
seminated. These nodules also sometimes occur in the 
skin apart from the tumors. The lesions are isolated as a 
rule, but may become confluent in patches. It is thought 
that they are due to emboli coming from some internal 
tubercular deposit. 

Etiology. — Lupus has long been regarded as a mani- 
festation of scrofula. It is now demonstrated that it is a 
tubercular disease. It should be placed under the title 
of Tuberculosis cutis, but usage makes it advisable to con- 
sider it by itself. Many patients with lupus are plainly 
tubercular; many, 55 T 9 ^ per cent, of Sach's 1 cases, are 
either tuberculous themselves or have a decided history 

1 Vierteljahr. f. Derm. u. Syph., 1888, xiii, 241. 



448 DISEASES OF THE SKIN 

of the occurrence of tuberculosis in their family. The 
tubercular history is far less pronounced in this country 
than it is in Europe. It is no uncommon thing for several 
members of the same family to have lupus. It is probable 
that we could find a close connection between lupus and 
infection with the tuberculous virus in all cases, were it 
practicable to do so. It has been noted frequently to 
follow piercing of the ears, and circumcision accord- 
ing to the Jewish rites, and, at times, vaccination. It 
frequently follows measles. Exceptionally the infection 
of the skin may take place by way of the lymphatics or 
bloodvessels from a tubercular focus more or less distant. 
Another evidence of its tubercular origin is found in the 
nearly uniform reaction of lupus to tuberculin. It is 
much more frequent in females than in males, about 
62 per cent, being in females according to Block's and 
Sach's statistics. It begins in more than half the cases 
before the fifteenth year. It may begin as early as the 
second year. It is almost always a disease of youth. 

Pathology. — The pathology of lupus has been studied 
by many competent investigators. "It is a neoplasm of 
the granuloma class, and consists of a small-celled infiltra- 
tion which begins in the deep part of the corium, and from 
thence gradually invades all the other skin structures," 
says Crocker. Giant cells are more numerous than usu- 
ally observed in tuberculous tissue, and there is greater 
formation of vascular connective tissue. In the older 
nodules the tubercular elements necrose and may be 
absorbed and replaced by connective tissue, or break 
through the thinned epidermis with consequent ulceration 
and secondary septic infection. The tubercle bacillus 
is found in the tissues, though sparsely. Inoculations of 
animals have not always been successful, but in a goodly 
number of cases the inoculations have been followed by 
general tuberculosis, so as to warrant our belief in the 
tubercular nature of the disease. It has been suggested 
that as the bacilli are present in but a small number the irri- 
tation of the tissues is due to the toxins produced by them. 



LUPUS VULGARIS 449 

Diagnosis. — Lupus is most commonly confounded with 
a tubercular or gummous syphilid. It may have to be 
differentiated from a scrofuloderm originating in a caseous 
gland, from an epithelioma, lupus erythematosus, and 
possibly lepra. From syphilis it is diagnosed by the 
presence of the characteristic apple-jelly tubercles; by its 
slow course; by its history; by the absence of all other 
signs of syphilis; by its little tendency to ulceration; by 
the superficial character of its ulcers and their slight 
crusting; and by its sparing the bones. If there is still 
any doubt, appeal may be made to the effect of treatment 
by means of the iodide of potassium and mercury, which 
will have no effect upon the lupus. As the scrofuloderm 
is another manifestation of the tubercular diathesis and 
amenable to the same treatment as that of lupus, its 
differentiation is not so important. It, however, will 
begin about a caseous and broken-down lymphatic gland 
or gumma, will probably have sinuses, and no character- 
istic tubercles. An epithelioma begins usually after the 
thirty-fifth year; has no tubercles; and forms a deep 
ulcer with raised, hard, waxy edges crossed with dilated 
bloodvessels. " The diagnosis from lupus erythematosus is 
given in the preceding section. Leprosy presents large 
tubercles which are anesthetic, and this at once decides 
in its favor. In any doubtful case a von Pirquet test 
should be made. 

Treatment. — As lupus is a tubercular disease, and 
sometimes is followed by tuberculosis of the lungs, care 
must be given to the general health of the patient, and he 
must be placed in the best possible hygienic surroundings. 
His diet should be nutritious, and cod-liver oil, iodin, 
the hypophosphites, and iron should be given. While 
these measures may not remove the lesions they place the 
patient in a better condition to resist the spread of the 
disease. The thyroid extract has been used with some 
benefit. Buch 1 reports the cure of a case, of fourteen 

1 Practitioner, 1901, xiv, 140. 
29 



450 



DISEASES OF THE SKIN 



years' standing, by the administration of urea. He began 
by giving 20 grains (1.33) three times a day and increased 
the dose gradually to 1 drachm (4) . Tuberculin injections, 
using the new tuberculin (T. R.) according to the new 
method of using small doses of 1 to 2 milligrams and 
increasing the dose by 2 milligrams, have done well in 
some cases. The injections should be followed by slight 
reaction and an increase to 1° F. in temperature. The 
injections may be repeated every two days. Bernhardt 1 
recommends as especially useful in the ulcerating forms 
combining salvarsan with tuberculin. He gives 0.3 of 
salvarsan, and four days afterward 1 milligram of tuber- 
culin, the latter being repeated in three and then in five 
days, and the salvarsan in sixteen days. 

Fig. 64 



Scarifying knife. 

But local treatment is of the greatest importance, 
and the disease must be gotten rid of root and branch. 
If a single diseased cell remains, the disease is sure to 
return. To effect its destruction surgical procedures had 
best be resorted to. The whole patch or patches may be 
scraped out with the dermal curette, and this followed 
by a 25 or 30 per cent, pyrogallol ointment for a week 
or ten days, and that in turn by mercurial plaster for 
another equal term. The pyrogallol will cause free sup- 
puration and destroy the cells left behind by the curette. 
A second or third course may be necessary. Piffard 
advised to touch the base left after curetting with the 
galvanocautery at a red heat. The wound is then to 
be packed with absorbent cotton. After about ten to 
fourteen days the crust and cotton will fall off and leave 
a soft, smooth, pliable cicatrix. Multiple scarifications 



1 Archv. Derm. u. Syph., 1913, cxiv, 401. 



LUPUS VULGARIS 451 

have proved of service. They may be made with a 
many-bladed instrument constructed for the purpose, or 
with a scalpel, or a knife shaped like a butcher's cleaver 
(Fig. 64). They must go deep enough to penetrate all 
the softened tissue, but not to wound the sound parts. 
The resistance offered by the healthy tissue will be suffi- 
cient guide for this. The scarifications should be so made 
as to divide the tissues into little squares, thus: 



They may be repeated in five or six days, and need no 
after-treatment. This is Vidal's method. The individual 
tubercles may be bored out with Morris' double-screw 
instrument, or with dental burrs and hooks dipped in 
pure carbolic acid, as proposed by Dr. George H. Fox. 
This is an excellent method. The galvano- or Paquelin 
cautery may be employed to destroy the patch. This 
will require the administration of an anesthetic, while 
the former procedures do not require it, or at most any- 
thing more than local anesthesia by means of cocain. 
Multiple punctures by means of the galvano- or thermo- 
cautery at somber red heat at 1 mm. distance for small 
patches and linear scarifications with cautery knife for 
large ones, followed by emplast. de Vigo, and repeated 
once a week, is Besnier's method. Electrolysis in mul- 
tiple punctures or by passing the needle through the patch 
or by means of a flat metallic button, is a useful mode 
of treatment. The current must measure 3 to 5 ma., 
and it must be continued for five minutes, when the 
button is used. Lang 1 advocates excision of the patches 
when not too large, followed by grafting. This method 
is to be preferred in small patches, and cures may be 
expected in more than half the cases. 

These surgical procedures have largely superseded the 

1 Dermat. Zeitschrift, 1900, vii, 805. 



452 DISEASES OF THE SKIN 

use of caustics, though the latter are valuable and may 
be used when the patient fears an operation. Arsenic 
may be employed in the form of a paste, such as Hebra's 
modification of Cosme's paste: 

1$ — Ac. arsenos, gr. x j 65 

Hydrarg. sulphuret, rubri, 5j 4 

Ungt. aq. rosse, ad §j 311 M. 

which is to be spread on lint or linen, applied evenly, 
and bound down firmly. It is to be left on for twenty- 
four hours, then removed and re-applied till ulceration is 
set up. It is painful. Vienna paste, equal parts of 
caustic potash and unslaked lime; or a chloride of zinc 
paste may be used, such as 1 part of zinc to three parts 
of starch. Both are painful. Many think highly of 
boring into the patch with the solid nitrate of silver stick. 
Salicylic acid, 20 to 25 per cent., in plaster or plaster- 
muslin, changed once or twice a day is good. It is well 
to combine creosote with the salicylic acid, .2 parts to 1, 
to allay the pain caused by the acid. The local appli- 
cation of bichloride of mercury in solution gr. j (0.06) to 
5j (32) to ulcerated forms, and in ointment to non- 
ulcerated forms, is commended by White and others. 

Unna 1 recommends painting with pure carbolic acid 
for from two or four days. He also has had good results 
with a salve-muslin containing 1 per cent, of bichloride 
of mercury, 20 per cent, of carbolic acid, and 30 per 
cent, of oxide of zinc. He 2 has also recommended the 
following procedure : Little sticks of hard wood are sharp- 
ened and then soaked for several days in a solution of 

1$ — Hydrarg. bichlor., gr. xv 1 

Ac. salicylici, 5iiss 10 ! 

Athens sulph., 3vj 24 

01. olivjfi, ad giij ad lOO! M. 

A stick is forced into each tubercle, cut off close to the 
skin, and covered with gutta-percha or carbolized mer- 

1 Monatshefte f. prakt. Dermat., 1891, xii, 341. 

2 Ibid., 1895, xxi, 281. 



LUPUS VULGARIS 453 

curial plaster. After two days the plaster is removed, 
leaving a surface covered with a thin layer of pus. The 
holes made by the sticks have become enlarged and the 
sticks lie loose in them. The sticks are removed, the sur- 
face aseptically cleansed, the holes filled with a powder of 



-Hydrarg. bichlor., 


gr. iss 


1 




Magnes. carbonat., 


3iiss 


10 




Ac. salicylici, 


3i gr. xv 


5 




Cocain. muriat., 


gr. viiss 


015 


M. 



which is blown on with a powder-blower and worked in 
by the fingers or with a wooden spatula. The patch is 
again covered with the plaster for twenty-four hours, 
when the procedure is repeated for another day. The 
subsequent treatment is by pyrogallol. 

C. Boeck's 1 treatment has been endorsed by others. 
He used a paste of 



1$ — Pyrogallol, 








Resorcin, 








Ac. salicylic, 


aa 


5j gr. xlv 


7 


Gelanthi., 








Pulv. talci, 


aa 


5j gr- xv 


5 



M. 

spread thickly upon the part with a wooden spatula and 
covered with a thin layer of absorbent cotton, which is 
allowed to remain for a week. If there is any ulceration 
it is best to paint it with a 5 per cent, solution of novo- 
cain, or 1 per cent, nitrate of silver and cover with a 
layer of anesthesin. The dressing is to be repeated until 
its action seems to have gone deeply enough. In lupus 
of the nasal opening he recommends a 10 to 15 per cent, 
ointment of pyrogallol, while for lesions of the mouth 
and pharynx painting the parts six to eight times daily 
with 



M. 



-Resorcin, 








Talcum, 


aa. 


3v 


20 


Mucilage of gum acacia, 




3iiss 


10 


Bals. Peruv., 




5j gr- xv 


5 



is best. 

1 Monatshefte f. prakt. Dermat., 1909, xxviii, 439. 



454 DISEASES OF THE SKIN 

S. Reines 1 endorses Ehrmann's method, which is to 
cover the part with a 33 J. per cent, resorcin paste spread 
on linen and bound' down. This is to be removed in 
twelve hours, and leaves the skin a grayish-white color. 
This gray pellicle is to be curetted off, and the paste 
re-applied, and the treatment so continued for five or six 
days. For the next two or three days a boric acid oint- 
ment is to be used. Return is to be had to the resorcin 
and the method followed out till cured. Large patches 
must be treated in small sections at a time. After the 
first four or five days the .T-rays may be used. A. W. 
Williams 2 reports the cure of one case and great im- 
provement in others by painting the part with a 5 per 
cent, watery solution of eosin until the skin is stained a 
distinct pink color, followed by exposure of the part to 
the direct sunlight for one or two hours daily. 

The most recent treatments of lupus are by the Ront- 
gen rays, phototherapy, the high-frequency current, and 
radium. The first two methods require expensive 
apparatus, and radium is very costly. In using pho- 
totherapy or F insert's method each sitting lasts one 
hour. The treatment must be repeated daily. It does 
not act well in ulcerative cases and in old cases which 
have been operated on and have a great deal of scar 
tissue. In suitable cases the cosmetic effects are very 
good. Good results have been obtained by the Kro- 
mayer lamp, the lamp armed with the blue glass window 
being pressed against the skin and exposures of one-half 
to one hour being given. The results from x-rays are 
more rapidly obtained, and are equally as good. According 
to MacKee only the ulcerative and hypertrophic types 
yield well to the rays. One or two treatments should 
be given of 4 to 6 Holznecht units and 8 to 10 Benoist. 
Radium is still on trial and reports from observers vary 
as to results obtained. The high-frequency current with an 
Oudin resonator and a carbon or platinum point may be 

i Berlin klin. Woch., 1905, xliii, 1161. 
2 British Jour. Dermat., 1907, xix, 43. 



LYMPH ANGIOMA CIRCUMSCRIPTUM l.V> 

used to destroy individual tubercles in patches of small 
size. 

Pkognosis. — The prognosis should always be guarded. 
Relapses after any plan are too often seen. A scar must 
result both from the disease and its treatment. The pos- 
sibility of the development of a general tuberculosis 
must also be borne in mind, although many patients 
preserve throughout the course of the disease a robust 
state of health. 

Lymphangiectasis.— Varices of the dermal lymphatics 
may be superficial or deep; and affect their trunk, 
meshes, or lacunas, though most commonly all parts are 
diseased. When they are superficial they form ampul- 
lary swellings at the surface of the skin which may be 
isolated or agglomerated. In size they vary from that 
of a millet-seed to that of a pea or larger. In color they 
vary with that of the skin. They break more or less 
easily and discharge lymphatic fluid. If deep, they can 
be more readily felt than seen, or form upon the surface 
of the skin isolated or associated raised cords which run 
a more or less tortuous course. After a time these also 
break and discharge lymph. 

Hallopeau and Goupil 1 describe under this title a dis- 
ease that they believe to be of tubercular origin, and that 
appears about a bony prominence of the extremities as a 
diffuse tumefaction or a cushion-like elevation resembling 
varicose vein tumors. They eventually open and dis- 
charge pure lymph or lymph mixed with pus. Fresh 
tumors arise in the course of the lymphatics in an ascend- 
ing series; also gummy nodes. The affected limb is 
swollen, indurated, and of more or less somber red. The 
prognosis is grave, and the proper treatment undetermined. 

Lymphangioma Circumscriptum. — Synonyms: Lymph- 
angiectasis, Lymphangiectodes, Lupus Lymphaticus, and 
Lymphorrhagica Pachydermia, is a rare disease. It con- 

1 Ann. de derm, et de syph., 1890, i, 957. 



456 DISEASES OF THE SKIN 

sists, according to Crocker, of a number of minute, 
deep-seated, shiny, translucent vesicles, closely crowded 
together in irregularly outlined groups of from one-third 
to one-quarter of an inch in size. These groups are 
arranged irregularly with healthy skin between them, 
or a few scattered vesicles in the otherwise healthy 
skin. They are usually confined to a single small area. 
The vesicles are deep-seated with thick walls, some of 
them almost warty-looking. They are pinpoint to 

Fig. 65 




Lymphangioma. (Epstein. 1 ) 

hemp-seed size, colorless or straw-colored, or pinkish, 
and contain a clear fluid. Some have vascular strise or 
tufts over them, others red clots, others contain extra- 
vasated blood. They run a chronic, non-inflammatory 
course, spreading slowly at the periphery, and tending to 
relapse if removed. Most of the few cases reported have 
occurred in males and begun in early childhood. 

The disease is of lymphatic origin, and the main 
feature is the dilated lymphatic vessels. 

1 By permission from Jour. Cutan. and Gen.-Urin. Dis., 1892, x, 214. 



MILIARIA 457 

The treatment consists in destruction by caustics, 
excision, or electrolysis; but relapses are liable to occur. 

Lymphangioma Tuberosum Multiplex. — This is a still 
more rare disease than lymphangioma circumscriptum, 
and consisted, in Kaposi's case, in the appearance all 
over the trunk and neck of hundreds of lentil-sized, 
rounded, brownish-red, smooth, glistening, disseminated, 
flat or elevated tubercles. They were firm and elastic, 
slightly painful, and upon some of them were dilated 
bloodvessels. One or two other cases of the same kind 
have been reported by others. The disease generally 
begins in childhood or early youth. By some this disease 
is regarded as a form of benign cystic epithelioma. 

Lymphosarcoma. — See Sarcoma. 

Maculae et Striae Atrophicae. — See Atrophoderma stria- 
tum et maculatum. 
Maculae Ceruleae. — See Pediculosis vestimentorum. 
Malignant Papillary Dermatitis. — See Paget's disease. 
Mask. — See Chloasma. 

Medicinal Eruptions. — See Dermatitis medicamentosa. 
Measles. — See Morbilli. 

Melung. — According to H. Ziemann, 1 this is a dis- 
ease that effects negroes on the West African coast. It 
begins between the tenth and fifteenth year of age, 
develops symmetrically, and affects only the hands and 
feet, stopping at the wrists or ankles. It takes the form of 
more or less round, oval, or irregular macules, which are 
reddish-white with a tinge of yellow. When the disease 
is fully developed the hands and feet have an extra- 
ordinary marbled or piebald appearance. It seems to be 
hereditary, and to affect more boys than girls. It is 
probably a form of vitiligo. 

Miliaria. — Synonyms: Sudamina; Lichen tropicus : Stro- 
phulus; (Ger.) Frieselausschlag; Schewissflechte ; Prickly 
heat. 

1 Archiv. f. Dermat. und Syph., 1905, lxxiv, 163. 



458 DISEASES OF THE SKIN 

This is a disease of the sweat glands due to excessive 
sweating, which may or may not be inflammatory, and is 
characterized by an eruption of discrete papules, vesicles, 
or pustules. Several varieties are described, but it is 
enough to distinguish two forms, namely, sudamina and 
lichen tropicus. 

Symptoms. — Sudamina, also called miliaria crystallina, 
is the form that is met with during the course of febrile 
diseases, especially when the fever ends by crisis, and 
occurs as an eruption of an immense number of small, 
closely crowded, but discrete, bright, pearly vesicles 
entirely without inflammation or subjective symptoms. 
They are most abundant on the trunk, especially upon 
its anterior plane, but may occur anywhere. After 
lasting a few hours or days they are absorbed and dis- 
appear by drying up, possibly with some scaling, or they 
may rupture and dry up. 

Lichen tropicus is very commonly seen in this country 
during warm weather. It may consist in an eruption of 
pinpoint, bright-red papules (miliaria papulosa); or of 
very small vesicles upon an inflamed skin (miliaria rubra) ; 
or the eruption may be a composite one of papules inter- 
spersed with vesicles and pustules. Whichever form it 
may assume, the lesions are present in great number, and 
closely crowded together, though not aggregated. It may 
involve the whole surface of the body, but is most com- 
mon on covered parts, and especially upon the trunk. The 
eruption is apt to become better or worse according to 
the changes in the temperature of the atmosphere. The 
disease may last in this way throughout the warm weather. 
It is no uncommon thing for furuncles to form, and even 
cutaneous abscesses. Itching, pricking, and burning are 
always annoying accompaniments. If the skin is much 
scratched, eczema may complicate the disease. The old 
nurse's "red gum," the strophulus of older writers, is a 
miliaria. Kaposi regarded the disease as an eczema. 

Etiology. — The cause of sudamina is retained sweat, 
owing, probably, to epithelial scales clogging up the sweat 



MILIARY FEVER 459 

pores when sweating is stopped on account of the fever. 
When the fever passes and the sweat glands resume their 
function the rush of sweat to the surface raises up the 
epithelium over the pores into little vesicles. They soon 
give way and the trouble is over. Lichen tropicus is due 
to congestion about the sweat pores and irritation of the 
skin when profuse sweating is induced by too warm cloth- 
ing and hot weather. It is also suggested that checking 
a profuse sweat may cause it. It is seen most commonly 
in babies and fat people. It is noticeable in New York 
that the children who live near the river front and are 
a good deal in the salt water escape the disease, while 
it is very common in the rest of the tenement-house 
population. 

Diagnosis. — Sudamina differs from vesicular eczema in 
its sudden occurrence during a febrile process; in being 
non-inflammatory; in its vesicles not breaking down 
readily and in not itching. Lichen tropicus differs from 
eczema in the minuteness of its papules; its sudden 
appearance; not forming patches which are moist; 
having a high atmospheric temperature as an evident 
etiological factor, and the tingling rather than the itching 
of the eruption. 

Treatment. — Sudamina needs no treatment, as with 
the subsidence of the fever it gets well of itself. Lichen 
tropicus requires attention to the diet, cutting off the meat 
in children and lessening its amount in adults. Cooling 
drinks and the administration of gentle saline laxatives 
are also advisable. Locally, bathing in salt water or 
alkaline lotions, and subsequently powdering of the skin, 
conjoined with wearing light clothing, and not using 
too warm bed covers, will relieve and ofttimes cure the 
trouble. 

Miliary Fever, or the sweating sickness, is an epidemic 
disease accompanied by profuse sweating and miliaria. 
The epidemics have occurred most often in France. It 
has not been observed for many years. It is described 



460 DISEASES OF THE SKIN 

as having prodromas of fever, nervousness, muscular 
cramps, constipation, cough, and nose-bleed. The eruption 
appears first on the face, from which it spreads over the 
trunk and extremities. It may be papular, vesicular, 
erythematous, or purpuric in character. After the erup- 
tion is over the skin may desquamate. Death results in 
from 12 to 33 per cent, of the cases. 

Milium. — Synonyms: Grutum; Strophulus albidus; 
Acne albida; Tuberculum sebaceum. 

Symptoms. — These are small pinhead- to split-pea- 
sized, firm, whitish or yellowish, slightly elevated papules 
that occur usually upon the face. They are spherical in 
shape, and slowly increase in size up to a certain point, 
when they remain stationary. When incised and pressed 
upon laterally a small, white, round, oval, or lobulated 
mass emerges. They give rise to no subjective symptom. 
While their most common site is the face below the eyes, 
they may occur anywhere on the face; and also upon 
the border of the lips, the penis, and scrotum. In this 
latter situation they are more decidedly yellow in color, 
flat, and often attain the size of a small bean. Along the 
corona glandis they are sometimes very thickly strewed. 
On the genitals of women their most frequent site is the 
labia minora. There may be but one or two, or a score of 
them. Occurring in the eye-lids they are called chalazion. 
When they undergo calcareous degeneration (an infre- 
quent occurrence) they form cutaneous calculi. Come- 
dones are often present at the same time with milia. 
Any part of the body may be affected. 

Etiology. — Milia occur chiefly in infants and young 
adults, and sometimes follow other diseases of the skin, 
such as pemphigus, erysipelas, or those in which destruc- 
tive processes have taken place and cicatrices formed. 
They are often congenital. 

Pathology. — They are supposed to be due to retained 
secretion on account of the upper layers of the stratum 
corneum growing over the openings of the sebaceous 



MOLLUSCUM CONTAGIOSUM 461 

glands, or to a non-development of the glands. Robinson 
thinks that some of them are due to "miscarried embry- 
onic epithelium from a hair follicle or from the rete," 
while those "following pemphigus, erysipelas, syphilis, 
and lupus consist of fatty epithelium and cholesterin, 
the epithelium being often arranged in concentric layers 
around a central flat nucleus. " 

Diagnosis. — They must be differentiated from xan- 
thoma. The latter are more of a lemon-yellow or buff 
color, and cannot be squeezed out when incised. Mollus- 
cum is sometimes mistaken for milium, but it is more 
prominent and hemispherical, and has a central punctum, 
out of which its contents can be squeezed without punc- 
turing its top. 

Treatment. — The treatment consists in pricking the 
top of the papule and pressing out its contents. To make 
sure of the destruction of the growth a drop of carbolic 
acid or iodin may be introduced into the cavity remain- 
ing. Hardaway advocates electrolysis as being the 
speediest and best treatment. If operative procedures are 
inadmissible, the skin may be caused to exfoliate by the 
use of green soap, salicylic acid, or resorcin ointment, 
when the milia will be destroyed. 

Prognosis. — Milia may disappear spontaneously from 
the skin of infants, but in older children and adults they 
remain unaltered indefinitely. 

Mole. — See Nevus. 

Molluscum Contagiosum. — Synonyms: Molluscum epi- 
theliale seu sebaceum seu sessile seu verrucosum; Epi- 
thelioma contagiosum; (Fr.) Acne varioliforme, Ecder- 
moptosis. 

Symptoms. — This is a contagious disease of the skin 
that occurs in most cases upon the face and in chil- 
dren, and is characterized by the appearance of one or 
more rounded pearly white or pinkish discrete tumors, 
varying in size from that of a pinhead to that of a large 
pea (Fig. 66). These tumors are waxy or opaque, and 



462 DISEASES OF THE SKIN 

on top are slightly flattened, and show an umbilication 
or small depression, out of which the soft cheesy contents 
of the tumors can be squeezed. They are at first very 
small, but gradually grow until they attain a certain 
size, when they may remain unchanged for an indefinite 
period; or they may become inflamed, break down of 
themselves, discharge their contents, and disappear 
either without leaving any trace or with a very slight 

Fig. 66 




Molluscum contagiosum. 1 

scar. Not infrequently scores of these tumors are found 
on the same subject. They are commonly sessile, but 
may become more or less pedunculated. The genitalia, 
breast, and scalp are affected next to the face in point of 
frequency, while the tumors may occur anywhere but on 
the palms and soles. They have an incubation period 
of several weeks or months. 

1 By the courtesy of Dr. S. D. Hubbard. 



MOLLUSC UM CONTAGIOSUM 463 

Etiology. — Children are far more often affected than 
adults. If adults are affected, it will usually be found 
that they are in attendance upon children who have 
molluscum. The bad hygienic conditions under which 
poor people live seem to predispose to the affection, as 
it is rare to meet with it among the well-to-do. There is 
little doubt that the disease is contagious. Though 
inoculation experiments have failed in most instances, 

Fig. 67 



Molluscum contagiosum. 1 

still there have been a few cases in which they were 
successful. In the spring of 1891 a child with molluscum 
contagiosum came into my service in Randall's Island 
Hospital, and within a few weeks, no attempt being made 
to destroy the tumors, there were six cases in the wards. 
Pathology. — The true pathological anatomy of these 
growths has not been settled, but the old idea that they 
spring from the sebaceous glands is no longer entertained. 
The rete seems to be the starting-point of the disease. 

1 By the courtesy of Dr. J. A. Fordyce. 



464 DISEASES OF THE SKIN 

One of the most characteristic features of the disease is 
the so-called " molluscum corpuscle," which is but a 
changed epithelial cell (Fig. 67). These appear, under 
the microscope, as large, ovoid, lustrous bodies, without 
nuclei, some being either wholly or partly contained in 
an epidermic envelope, . and some being entirely un- 
covered. Several parasites have been declared to be the 
cause of the disease by different investigators. Charles 
J. White and W. H. Eobey, 1 after careful investigation, 
state that the disease is not parasitic, and that the mol- 
luscum bodies are an extraordinary metamorphosis of 
the rete cells into keratin. 

Diagnosis. — The appearance of this disease is so 
characteristic as to be diagnostic. It is most apt to be 
confused with milium; but if it is remembered that a 
milium has no central depression, while a molluscum 
has, the confusion will exist no longer. If the lesions are 
taken for the vesicopustules of variola, a hardly probable 
occurrence, pricking their tops will at once show that they 
are not pustules, and if they are watched for a day or 
so it will be found that they remain unchanged. Warts 
do not have the pearly appearance of molluscum and 
their central punctum. 

Treatment. — The speediest way of getting rid of the 
tumors is to scrape them off with a curette. To insure 
their not returning it is advisable to touch the base of 
each tumor with a drop of carbolic or stronger acid. Or 
it is sufficient to make a small slit in the top of the 
tumor with a scalpel, squeeze out the contents, and touch 
the base with carbolic acid. If operative measures are 
refused strong boric acid lotions, or salicylic acid 3 per 
cent, in sulphur ointment may be used. 

Molluscum Fibrosum seu Pendulum. — See Fibroma. 

Morbilli.— Synonyms: Rubeola; (Ger.) Masern; Measles. 

This is one of the contagious exanthemas. Its stage 

of incubation is from eight to twenty-one days, usually 

1 Jour. Med. Research, 1902, vii, 255. 



M0RB1LLI 465 

from ten to twelve days. It is characterized by prodro- 
mas of marked catarrhal symptoms, such as conjuncti- 
vitis, coryza, and bronchial inflammation, more or less 
fever, and constitutional disturbance; and then, on about 
the third day, an eruption of small red, flat papules or 
macules that rapidly enlarge, and unite with others to 
form mulberry-colored little patches often of a crescentic 
shape, with areas of sound skin between. H. Koplik 1 
calls attention to the fact that one or two days before the 
eruption appears on the skin there will be found on the 
buccal mucous membrane and on the inside of the lips 
small, irregular, bright-red spots with a minute bluish 
speck in the centre. The eruption begins on the face and 
neck, spreads downward, and covers the whole body in 
about a day and a half. The fever begins to decrease 
on the second day of the eruption. The rash begins 
to disappear by the third or fourth day, and is gone by 
the ninth day. Furfuraceous desquamation follows the 
subsidence of the exanthem. Sometimes it is so slight 
as to be hardly noticeable, and it is never so marked as 
in scarlatina. 

In atypical cases there may be scarcely any disturbance 
of the health, and the eruption may be so slight as to be 
hardly noticeable; or the onset may be marked by high 
temperature; or the eruption may be excessive or hemor- 
rhagic. The last is the most dangerous form. 

Diagnosis. — The only dermatoses with which measles 
is apt to be confounded are an erythema, rotheln, or 
German measles, variola, and the macular syphilide. But 
the catarrhal symptoms; the regular progression of the 
eruption from above downward ; and the crescentic, patchy 
arrangement and dark color of the lesions are sufficient to 
differentiate it. In erythema we may have some constitu- 
tional disturbance, but it is of short duration; the erup- 
tion is more pronounced on the trunk and extremities, 
and shows no order of progression; the color of the erup- 

1 Arch. Pediat., Dec, 189fi. 
30 



466 DISEASES OF THE SKIN 

tion is a brighter red; there is an absence of crescentic 
arrangement; and very often an accompanying urethritis 
will suggest the ingestion of some of the balsams as a 
cause of the trouble. In rotheln there is not so much 
constitutional disturbance, less catarrhal complications, 
and a pronounced swelling of the glands of the neck. 
The eruption is usually a remarkably fine papular one, 
not so patchy as in measles and of shorter duration. 
Variola in its early stage is sometimes difficult to diag- 
nose from measles. Backache is usually a marked symp- 
tom in variola; its papules are smaller, harder, and more 
shot-like, and lack the crescentic arrangement of measles. 
The subsequent course of the disease is, of course, very 
different from that of measles. The erythematous syphilid 
affects the sides of the chest and the abdomen more than 
the face; the rash lasts for weeks after any possible fever 
has passed; its lesions have no definite arrangement and 
come out in successive crops, so that at the same time 
there will be present lesions of different age, and staining 
of the skin from those that have gone. 
Treatment is purely symptomatic. 

Morphea. — See Scleroderma. 

Morvan's Disease is a disease of the spinal cord which 
causes profound cutaneous lesions, such as ulceration, 
bullae, and fissures of the palmar side of the hands and 
fingers, and paronychia and necrosis of several phalanges. 
It is allied to, if not identical with, syringomyelia, wmich see. 

Moth Patch. — See Chloasma. 
Mother's Mark. — See Nevus. 

Multiple Fungoid Papillomatous Tumors. — See Mycosis 
fungoides. 

Myasis Externa Dermatosa is a dermatitis due to the 
penetration of the skin by certain kinds of flies, which lay 
their eggs under the skin. These subsequently hatch 
out and give rise to the dermatitis. 



MYCOSIS FUNGOIDES 
Mycetoma. — See Fungous foot of India. 



467 



Mycosis Fungoides. — Synonyms: Inflammatory fungoid 
neoplasm; Multiple fungoid papillomatous tumors; 
Fibroma fungoides; Lymphadenie cutanee; Granuloma 
fungoides; Eczema hypertrophicum seu tuberosum; Ulcer- 



Fig. 68 




Mycosis fungoides. 



ative scrofuloderm; Lymphodermia perniciosa; Sar- 
comatosis generalis; Multiple sarcoma cutis; Fungoid 
dermatitis; Beerschwamahnliche multiple Papillargesch- 
wiilste der Haut. 

1 Courtesy of Dr. H. Fox. 



468 DISEASES OF THE SKIN 

A chronic progressive disease of the skin, characterized 
by the appearance with or without an antecedent erythe- 
matous or eczematous stage, of fungating tumors that 
tend to break down and ulcerate. It leads, through 
marasmus, to death. 

Symptoms. — The many names that have been applied 
to this rare disease testify to the uncertainty of our knowl- 
edge of its proper place in the .classification of skin dis- 
eases. It assumes so many forms that it is impossible in 
our limited space to give a complete picture of the disease. 
In some cases the first thing noticed is what appears to 
be a simple eczema, erythema, urticaria, or psoriasis in 
variously sized patches, tending to be round or circinate 
in form, and accompanied by marked pruritus. One 
characteristic of one variety of prodromal erythema is 
that the macules arrange themselves in circles in the 
centre of which is a single macule like a bull's eye. These 
lesions occur anywhere, and constitute the first or premy- 
cosic stage of the disease. They may disappear for a 
time, to reappear in the same places or elsewhere. Ex- 
ceptionally this stage is wanting. After some months, 
or two or three years or more, the patches become raised, 
glistening, and infiltrated, more deeply red, and pea-sized 
papules form. These disappear, and new ones form. 
This is the second stage, and may last months or years. 
Then the characteristic tumors form either by the papules 
enlarging and coalescing, or as tumors at once rising out 
of the sound skin, without an antecedent erythematous 
stage. The tumors are oval, hemispherical, annular or 
irregular in shape, sharply defined, sometimes slightly 
pedunculated. They are of whitish, bright-red, bluish- 
red, or dark-red color. They are sometimes hard and 
elastic, sometimes soft and succulent. The epidermis 
over them is tense, thin, and glistening. They may be 
absorbed and disappear, new ones appearing; or they 
may become necrotic and ulcerate. In size they vary 
from that of a pea to that of the fist. At first they occur 
only on the trunk and may limit themselves to a single 



MYCOSIS FUNGOIDES 469 

region; later, they come anywhere, and involve even 
the mucous membrane of the mouth. When ulcers 
form from breaking down of the tumors they are horse- 
shoe-shaped or crescent ic with round, broad edge. The 
itching and pain continue well into the tumor stage, 
when they may lessen. The lymphatic glands enlarge 
painlessly. The hair falls from over the tumors. The 
general health of the patient is undisturbed for a long 
time, but at last a general marasmus sets in and the 
patient dies, usually from an uncontrollable diarrhea or 
some lung complication. There has been but one case 
of recovery reported. 

Etiology. — The majority of the cases have been in 
men over forty years old. The disease is held not to be 
contagious by some, while others hold the opposite 
opinion. Blanc 1 found in one case that there w T as a marked 
reduction in the white-blood corpuscles, their proportion 
to the red being 1 to 130, instead of 1 to 350 or 500. 
Various microorganisms have been found in connection 
with the disease, but no one has been settled on as the 
cause. This is about all that is known of the etiology 
of the disease. 

Pathology. — The earliest histological changes are 
edema and dilatation of the bloodvessels and the lymph 
capillaries, often accompanied by some slight endothelial 
proliferation. Soon the corium is marked by an infiltra- 
tion which may be diffuse or circumscribed in irregular 
patches, spreading outward from the vessels. In the 
centre of an infiltrated region the cells are densely packed 
and the structure bears a strong resemblance to an invad- 
ing small round-celled sarcoma, but at the edges the true 
infiltrating granulomatous nature of the growth is always 
evident, and the multiform character of the infiltrating 
cells can more easily be made out. There are many small 
round cells, and fewer plasma, mast, multinuclear and 

1 Jour. Cutan. and Gen.-Urin. Dis., 1888, vi, 256. 



470 DISEASES OF THE SKIN 

giant cells, all of great diversity in size, shape and stain- 
ing qualities. Mitoses and cell fragments are numerous 
and indicate cell proliferation and degeneration. Usually 
there is also some diapedesis of red-blood corpuscles. 

At first the epidermis may be unaffected, but more often 
it shows various changes such as edema, acanthosis and 
parakeratosis. The rete may hypertrophy, mitotic figures 
appear, and the interpapillary processes become long 
and thick. But as the granulomatous tissue gradually 
increases in amount, causing the growth to project above 
the surrounding surface, the epidermis begins to show the 
effects of stretching and impaired nutrition, the rete 
thins out until it may consist of only a single layer of 
cells, and finally ulcerates. 

In the last stages there is extensive crenation or frag- 
mentary degeneration of the granulomatous cells accom- 
panied by a basophilic disintegration of the fine col- 
lagenous and elastic tissue net-work which supports the 
growth. 

While much study has been given to the pathology of 
the affection there is no agreement among pathologists 
as to its essential nature. By many it is supposed to 
belong to the class of infecting granuloma. 

Diagnosis. — The diagnosis of the disease in its early 
erythematous stage is very difficult, and probably cannot 
be made with certainty. There is something peculiar in 
the sharply circumscribed outline, the chronicity, circinate 
form, and capriciousness of the patches and the intense 
pruritus. Psoriasis affects other localities at first, its 
patches are not so infiltrated, and it is more scaly. Eczema 
is a moist disease at some time and more multiform in 
character. When the tumors develop, and the capricious 
manner of their coming and going is observed, the diag- 
nosis is more evident. 

Treatment. — Kobner reports the cure of a case by 
means of hypodermic injections of arsenic. Crocker 
speaks encouragingly of salicin in all stages before ulcera- 
tion takes place. A general tonic treatment is always 



MYOMA 471 

indicated. Locally, pyrogallol; ichthyol; mercurial oint- 
ment; injections of carbolic acid; resorcin, and camphor- 
ated naphtol have been used, and may be tried. The 
itching is most rebellious to treatment and demands the 
use of antipruritics. The tumors, when not in great num- 
bers, may be cut out, though the operation is of doubtful 
utility. The ulcerations that result from breaking down 
of the tumors must be treated on surgical principles. 

In x-rays we have a means of curing the intense itching 
and causing a complete disappearance of all the lesions. 
MacKee advises that each tumor be given a dose of H. 2 
to 4; and B. 8 to 10. Too many tumors should not be 
treated at one sitting for fear of systemic poisoning. 
Though at first relief from the itching is obtained and the 
tumors disappear, later the itching and the tumors may 
return and be uninfluenced by the rays. Nevertheless, it 
is the only treatment that has availed at all, and should 
be tried. 

Prognosis. — Death is the outcome of the disease, and 
it may occur in from a few months to fifteen years, the 
average time being from two to four years. 

Myoma. — Like most of the tumors, so this one concerns 
the surgeon more than the dermatologist. Two main varie- 
ties are described, namely, simple myoma or leiomyoma, 
and dartoic. Myomata may be single or multiple. They 
are composed of muscular fibers, and vary in size from 
that of a split pea to that of an orange. They are painful 
on pressure, and sometimes spontaneously. They are pink 
or red in color, or of that of the sound skin; disseminated 
or aggregated into patches, though still retaining their 
individuality. The epidermis over them is unchanged. 
The single tumors may be sessile or pedunculated, and 
may attain the size of an orange. They may occur 
anywhere, but principally on the arms. The dartoic 
variety has its seat most often on the female breasts, and 
on the genitalia of both sexes, and is usually a single 
tumor. Simple myomas are more commonly multiple, 



472 DISEASES OF THE SKIN 

and occur upon the upper extremities, though they may 
occur anywhere on the body. Most of the cases are in 
middle-aged or elderly men. They may be congenital. 
If they contain a good deal of fibrous tissue, they are 
called fibromyoma; if they contain large bloodvessels, 
they form angiomyoma; or, if the lymphatics are involved, 
we have lymphangiomyoma. The diagnosis is often 
difficult without the aid of the microscope. Excision is 
the only thing that can be done for them. 

Myxedema. — This is a constitutional disease with 
cutaneous symptoms. The skin becomes waxy pale, 
yellowish, shining in some places, dull and earthy- 
looking in others; it is dry, scaly, exfoliating on the 
extremities, sometimes ulcerated, and verrucose on the 
lower limbs. The fingers and toes are sometimes livid. 
There are partial or general alopecia, and deformity 
and fragility of the nails. There is a general edematous 
swelling of the whole integument as well as of the mucous 
membranes, and this edema does not pit on pressure. 
The swelling is most marked on the face. The skin about 
the eyes becomes puffed up so as almost to close the 
eyes. Cushions of fat fill the supraclavicular spaces. 
There is atrophy of the thyroid gland. The patient's 
intellectual faculties become dulled, the speech is slow, 
and the gait unsteady. • 

The disease affects women far more often than men, 
and involves all parts of the body. There are enfeeble- 
ment of mind, and a great impairment of the senses of 
touch, taste, and smell; a torpidity of movement and of 
the digestive function. It ends fatally either by maras- 
mus or by complications on the side of the internal organs. 

The diagnosis in the early stage is difficult; when fully 
developed it could hardly be taken for anything else. 
The cause of the disease is unknown. 

Treatment. — All the symptoms are removed by the 
use of thyroid extract or powder, improvement being 
rapid. When the treatment is stopped the patients after 



NEVUS PIGMENTOSUS 473 

a time lapse into their former state, so that the adminis- 
tration of the thyroid has to be more or less continuous. 

Nettlerash. — See Urticaria. 
Neuralgia Cutis. — See Dermatalgia. 

Neuroma Cutis is an exceedingly rare disease, of which 
but a few cases have been reported. Neuromata are 
small, flat, pinkish or pale-red, firm tumors firmly im- 
bedded in the skin. They are painful spontaneously and 
on pressure. The pain may be paroxysmal in character. 
They are relievable by cutting out part of the nerve with 
which they are connected. 

Nevus. — A nevus, strictly speaking, is a congenital 
mark or growth in the skin, which may be either pigmen- 
tary or vascular. The name is occasionally applied to 
acquired new growths similar to the congenital ones. 

Nevus Anemicus. — This is a congenital defect in the 
skin which appears as one or more pale unelevated areas. 
When the skin is rubbed they remain pale while the sur- 
rounding skin is reddened. They are due to a deficiency 
of the blood supply to the areas. 

Nevus Pigmentosus. — Synonyms: Nevus spilus; Nevus 
pilosus; Nevus verrucosus; Nevus lipomatodes (Ger.); 
Fleckenmal, Pigmental, Linsenmal, Pigmentary mole; 
Mother's mark. 

A congenital, circumscribed hyperpigmentation of the 
skin, often accompanied by a growth of coarse hair and 
hypertrophy of the connective and fatty tissues. 

Symptoms. — These growths are closely allied to lentigo 
and chloasma, as an hypertrophy of pigment is a promi- 
nent feature of them. When they consist of pigment 
only, and are not raised above the surface of the skin, 
they are called nevus spilus. When besides the pigment 
there is an hypertrophy of the connective tissue, and they 
are raised and uneven, the name nevus verrucosus is 
applied to them; or nevus lipomatodes if they are soft 



474 DISEASES OF THE SKIN 

and contain fatty tissue; if hair grows from either form, 
then we speak of nevus pilosus. In color they vary from 
a light to dark brown or black. According to Dubreuilh 
and Petges 1 they may be of blue color, flat or raised, 
sharply limited, lentil size, and look like an India ink 
mark. Other forms of pigmentary nevi are often present. 
In size they vary from that of a split pea to that of an 
area large enough to cover the whole back. Most corn- 



Nevus lipomatodes. 

monly they are of small size. They may be located 
anywhere, though most often on the face, neck, and 
back. There may be but one or two or hundreds of 
them. They may have no special distribution, or they 
may occur in streaks or bands. They may be unilateral 
or bilateral, and sometimes symmetrical. If hair is in 
them, it is coarser, stiffer, and generally darker than 
that of the head. Sometimes large, hairy moles bear a 

1 Annal. derm, et syph., 1911, xi, 552. 



NEVUS PIGMENTOSUM 



475 



strong resemblance to the fur of animals. They grow 
in proportion to the growth of the individual, and cease 
growing when he has attained his growth. They are 
usually congenital, but may be acquired, and are liable 
to undergo malignant change in advanced life. They give 
rise to no subjective symptoms. They are permanent 
growths. They rarely disappear of themselves. 

Fig. 70 




Nevus pilosus. 1 

Etiology. — They are congenital growths, as a rule. 
The small pigmentary nevi so often seen on the trunk 
in adults, sometimes spoken of as permanent freckles, 
often are acquired. To account for the appearance of 
these malformations we have only the theory of nerve 
influence, and that is by no means satisfactory. Their 
name of "mother's mark" shows that the popular super- 
stition agrees with the scientific theory. We can simply 
regard them as anomalies.' 

1 By courtesy of Dr. S. Dana Hubbard. 



476 DISEASES OF THE SKIN 

Diagnosis. — Moles differ from lentigo in being con- 
genital and permanent, and in an hypertrophy of connec- 
tive tissue and a growth of hair being connected with 
them. The difference between hairy moles and hyper- 
trichosis is in the substratum; in the latter the underlying 
skin is otherwise normal. Moreover, moles occur in 
definite patches. 

Treatment. — We can destroy these growths and leave 
behind but little scar. If there is but a single pigmen- 
tary mole, it may be cut out. In this case it will leave a 
linear scar. It is generally better to destroy the growth 
by touching it over carefully with nitric or trichloracetic 
acid. This is done by stippling, as it were, making a 
row of dots in this fashion — 



At the time of the next visit a row of dots should be 
made in between the former ones, and so the stippling is 
to be continued until in course of time the nevus is de- 
stroyed. If done with care and slowly, the result is very 
good. Fuming nitric acid is best. Electrolysis by multiple 
punctures, or by transfixing the mole and making tracks 
in various directions, is a sure and speedy way. They 
may be destroyed by sparking with the high-frequency 
current. J. Brault 1 recommends tattooing them with a 
solution of 30 parts of chloride of zinc and 40 parts of 
sterilized water. The eschar falls in five to ten days. It 
may be necessary to repeat the process. 

Hairy moles are best destroyed by electrolysis, as in 
superfluous hair, only here a coarser needle may be used, 
as we are not so particular about a little scarring. In 
extensive hairy moles Rbntgen rays may be used to cause 
a fall of the hair, when we can work better with acids 
upon the pigmentation. Radium will remove all forms 
of nevus. Freezing by liquid air, or the snow made by 

1 Ann. de derm, et de syph., 1895, vi, 33. 



NEVUS VASCULARIS 477 

carbon dioxide, is a speedy and reliable method. If done 
with care the scar is good. It is the method of choice. 
The warty growths may be removed by a curette. 

Nevus Unius Lateris. — See Papilloma lineare. 

Nevus Vascularis. — Synonyms: Xevus vasculosus seu 
sanguineus; Angioma; (Ger.) Feuermal, Gefassmal; (Fr.) 
Tache de feu, Tache vasculaire; Port-wine mark, Birth- 
mark, Claret stain. 

Symptoms. — These are composed mainly of vascular 
tissue, and are congenital or appear during the first month 
of life. They are usually single, but may be multiple. 
They vary greatly in size, shape, and color, but all possess 
one feature in common — they pale under pressure. They 
may be pinhead-sized spots, not raised above the surface of 
the skin; or they may form large, erectile, elevated, pulsat- 
ing tumors; or they may spread out so as to involve a 
large area. They may be pink, bright red, dark red, or 
even purple in color. When on the face they become more 
pronounced on crying, coughing, and the like. They 
may disappear spontaneously; increase in size during 
a few months or years; or, most commonly, remain 
unchanged. According to their size they have received 
various names. The small, flat, or scarcely raised nevus 
composed of capillaries is called nevus simplex, or capil- 
lary nevus. This is the form very often seen in children, 
on the lips, or nape of the neck. It is not infrequent for 
it to disappear of itself after a while, leaving either no 
trace or a delicate atrophic scar. When it is so large as 
to form a patch as big as the hand or larger, it is called 
nevus flammeus, or port-wine marl;. The surface of this 
form is often uneven and studded with small erectile 
vascular tumors, or, may be, pigmentary moles. It often 
becomes dark purple after exposure to cold. The large 
erectile pulsating tumors are called nevus tuberosus, angi- 
oma cavernosum, venous nevus. They differ very much 
from the other forms in appearance and formation. 
Their surface is uneven and lobulated. This form is 



478 DISEASES OF THE SKIN 

apt to increase in size, and may attain enormous dimen- 
sions. Blue nevi, or benign melanoma, are steel-blue 
macules 3 to 4 mm. long, and 2 to 3 mm. wide, round 
or oval, looking like powder grains. At times some 
slight thickening of the skin may be felt. They are 
located on the extremities or face, and usually there is 
but one. 

Nevi may occur anywhere on the body, but are most 
frequent on the head and face. They may also occur 
upon the mucous membranes primarily or secondarily. 
The back, nates, pudenda, and lower limbs are said by 
Crocker to be the most common sites of the cavernous 
form. All forms of nevi may be hardly perceptible at 
birth, but become gradually more evident afterward. 

Etiology and Pathology. — Vascular nevi are prob- 
ably always congenital malformations, though their 
appearance upon the skin may be retarded for some 
time. Their frequent occurrence on the nape of the neck 
suggests local injury either during gestation or par- 
turition. The simple capillary nevi, which include the 
port-wine marks, are simply an increase in number and 
size of the capillaries. In the venous nevi we have also 
a new growth of connective tissue forming a mesh-work, 
and they are supplied directly by an artery without the 
interposition of capillaries. Women are more prone to 
nevi than are men. 

Diagnosis. — There can be no difficulty in diagnosis, 
excepting that a nevus may be taken for a telangiectasis. 
This error would be of little consequence, since the latter 
is simply an acquired nevus, and differs chiefly in having 
a central red point from which the dilated capillaries 
radiate. 

Treatment. — Electrolysis may be used for the de- 
struction of these growths. The current strength should 
be from 2 to 3 milliamperes. The best way to use it in 
capillary nevi and port-wine marks is by making multi- 
ple punctures in parallel rows, perpendicularly to the skin 
and down through its entire thickness. To expedite 



NEVUS VASCULARIS 479 

matters, one may use either a circle of needles set in a 
handle, or a row of three needles. The negative pole is 
to be connected with the needle-holder, and the operation 
is to be conducted in the same way as in removing 
superfluous hair. By this method it is possible to destroy 
small nevi entirely, and to diminish very much the 
unsightly appearance of large port- wine marks. As 
electrolysis necessarily destroys the skin, a scar will be 
left. But this is less conspicuous than the nevus, and if 
the operation is carefully done the scar is soft, smooth, 
and pliable. There is also much less danger of a de- 
forming scar from the use of a single needle than from a 
group of them. Therefore, this method is preferable, 
though more tedious. The punctures must not be made 
close together; at least a sixteenth of an inch should be 
left between them. After the nevus has been carefully 
gone over, it should be left alone for a couple of weeks 
or more for the full effect of the operation to be seen. It 
can be done over again, and another interval of time 
allowed, and so on until the growth is destroyed as much 
as possible. 

Besides electrolysis we may use multiple scarifications 
obliquely to the skin, or high-frequency cauterization. 
Or we may use the ethylate of sodium freshly prepared 
and applied to the absolutely dry skin, using a brush 
or glass rod. To avoid scarring, only a small part of 
the nevus must be attacked at a time. A crust will 
form, which must be left to come away of itself. Fuming 
nitric acid, or the acid nitrate of mercury or trichlor- 
acetic acid, may be stippled over the growth, care being 
had that the little dots are made in rows with spaces 
between equal to the size of the dots. At the next sitting 
the dots should be made between the first ones. In 
this manner the stippling is carried out until the nevus 
is destroyed. Or vaccination may be performed over it; 
or multiple punctures may be made by means of a steel 
needle dipped in nitric or carbolic acid. Marshall Hall 
advocates breaking up the nevus by introducing a cata- 



480 DISEASES OF THE SKIN 

ract needle close to the edge of the growth, pushing it 
across to the opposite side, then nearly withdrawing it, 
and again pushing it in at a little distance from the 
first puncture. These nevi have been cured by x-rays, 
radium, and the Kromayer lamp. Most excellent 
results may be obtained by the use of liquid air or car- 
bonic dioxid snow. In some cases the scars left are 
hardly perceptible. It is not successful in port- wine 
marks. These are almost impossible to remove. We 
have found cauterization with the high-frequency current, 
using a carbon or metallic point, a good means. 

For cavernous nevus we may use electrolysis also, but 
here we pass the needle obliquely into the skin in the hope 
of striking the deep vessels. It is well, sometimes, to 
pass the needle from the edge deep under the nevus and 
clear through to the other side, let the current pass for 
half a minute, partially withdraw the needle, and again 
push it in another direction, so as to avoid scarring as 
much as possible. Some prefer introducing two needles, 
connected each with one pole of the battery, in opposite 
directions. A platinum or gold needle must be used with 
the positive pole. A current strength up to 5 milliam- 
peres is often necessary to destroy these growths. Exci- 
sion may be performed, but sometimes this gives rise to 
alarming hemorrhage. Multiple punctures with a steel 
shoemaker's awl, heated to a red heat and allowed to cool 
to a black heat, or the point of a Paquelin or galvano- 
cautery heated to a dull red, are other good methods of 
treatment. It has been proposed to use a metallic plate 
perforated with a number of holes with which to exercise 
strong pressure upon the nevus while the galvanocautery 
is introduced through the holes. Injections of carbolic 
acid, perchloride of iron, alcohol, and the like are some- 
times effectual but always dangerous methods. Wyeth 
uses injections of water at a temperature of 180° to 
200° F., injecting 10 to 60 drops and repeating the injec- 
tions every three or four days. There is some danger of 
embolism from this method. Setons are not used as 



NON-ER Y THE MA TO US NOD ULES 481 

much as formerly. Compression by an elastic bandage 
is at times curative when the nevi are located over bony 
prominences. 

As many capillary nevi in children disappear in time 
it is advisable not to interfere with them at once, con- 
tenting ourselves with painting them with collodion and 
waiting until the child is old enough to desire their 
removal. Unna thinks that the addition of 10 per cent, 
of ichthyol to the collodion increases its efficacy. Of 
course, if they are very unsightly we cannot wait, nor 
should we temporize with cavernous nevi. In children 
one works more comfortably by using an anesthetic, but 
it is not absolutely necessary. Keloidal scars may be an 
unfortunate result of treatment in some cases. 

Prognosis. — The prognosis should be guarded, and 
the cases carefully watched. All nevi may increase in 
size, though very many remain stationary. There is 
always danger from hemorrhage in angiomas. Many 
of them disappear spontaneously, probably by plugging 
of the supplying bloodvessel. Scarring, more or less 
evident, must be expected from our efforts to destroy 
the growths. 

Nevus Verrucosus. — See Papilloma lineare. 

Nodules, Non-erythematous of Arthritics. — Brocq applies 
this name to cutaneous and subcutaneous tumors that 
he has met with in connection with the gouty diathesis 
They are of two varieties. The first one he calls 
ephemeral cutaneous nodules. They occur upon the fore- 
head and form ill-defined elevations of the skin, of small- 
pea to hazel-nut size, and entirely painless. They are 
movable with the skin, though sometimes they are adher- 
ent. They appear first during the night and disappear 
within twenty-four hours. 

The second variety is the subcutaneous rheumatismal 

nodule. It forms a small tumor resembling a gumma. 

The skin slides freely over it in most cases. The color 

of the skin is unchanged. It is firm and elastic to the 

31 



482 DISEASES OF THE SKIN 

touch. Generally such tumors are painful on pressure, 
at times spontaneously. In size they vary from that of 
a pea to that of an almond, and they are sharply defined. 
They may remain for days or weeks, when they disap- 
pear, leaving no trace. They often come in successive 
outbreaks. Their seat of predilection is about the joints, 
and upon the fibrous tissues that cover the superficial 
bones. They are generally discrete, and frequently very 
numerous. Their appearance often coincides with symp- 
toms of pericarditis or pleurisy. Their treatment is that 
appropriate to the rheumatism that seems to be their 
cause, especially iodin and the iodids. 

Nodulus Laqueatus is that condition of the hair in which 
it seems to tie itself into knots. The hair is usually dry 
and curly. It is probably caused by handling of the 
hair, and does not occur spontaneously. 

(Edema Cutis, Acute Circumscribed. — This disease is also 
called angioneurotic oedema, acute idiopathic oedema, peri- 
odic or giant swelling. It is a question whether this is a 
form of urticaria or not. It is certainly allied to it in the 
suddenness of its onset; in the attending erythema and 
digestive or other constitutional disturbances; and in the 
character of its lesions. It differs from urticaria in being 
recurrent in the same locations; in the shading off of the 
swellings into the surrounding skin; and at times in being 
unattended by itching. It is prone to occur upon the 
face, and there often closes one or both eyes in an enor- 
mous swelling; or the lips so that the mouth cannot be 
opened. In some cases a history may be obtained of the 
occurrence of the same disease in other members of the 
family. It usually begins in early adult life and tends to 
recur. It may occur on the mucous membranes, causing 
suffocative attacks if the larynx is involved, and acute 
digestive disturbances if the stomach is affected. It occurs 
in various parts of the body as swellings which may be the 
color of the normal skin, pinkish, or dull red, that appear 
suddenly and disappear in a few hours, or persist for 



OIDIOMYCOSIS 483 

several days. While these do not itch, the patient com- 
plains of burning, tension, and throbbing. In the pres- 
ent state of our knowledge it is probably well to regard 
it as urticaria edematosa. The treatment is the same as 
in urticaria. (See Urticaria.) 

(Edema Neonatorum. — This disease was formerly con- 
founded with sclerema, but is now separated from it. 

Symptoms. — It is a rare disease, that begins upon the 
legs within the first three days of life. The oedema 
spreads upward along the thighs, shows itself upon the 
hands, then upon the genitals and back. It may begin 
on the back or face, or the hands may be affected at the 
same time with the legs. It is hard and pits only on 
deep pressure. The skin is of a violaceous red or more 
or less intense yellow, and feels cold. The infant is coma- 
tose; its pulse is feeble; its breathing labored; and its 
cry sharp. A high temperature may exceptionally be 
present. Death usually results on account of some pul- 
monary affection or from collapse. Exceptionally, re- 
covery takes place. 

Etiology. — The disease occurs in feeble, ill-nourished 
children, in those prematurely delivered or exposed to 
poor hygienic surroundings. 

Diagnosis. — It differs from sclerema in being more 
limited to certain localities; in the skin being more livid 
from the first, and not so hard; in affecting the depen- 
dent parts; and in lacking the stiffness of the joints. 
(Crocker.) 

Treatment. — Though the prognosis is exceedingly 
bad, an attempt should be made to nourish the child as 
well as possible by artificial feeding; it should be wrapped 
in flannel and kept warm; and the limbs should be rubbed 
with warm oil, or camphorated alcohol, in such a way that 
the blood is forced toward the heart. 

Oidiomycosis is due to the infection of the skin with 
the oidium cutaneum. It is marked by the eruption 
of ulcerating gummatous nodes, and resembles bias- 



484 DISEASES OF THE SKIN 

tomycosis, syphilis, and sporotrichosis. The diagnosis is 
made by cultivating the fungus. 

Onychauxis, Onychogryphosis. — These are both hyper- 
trophies of the nail, either in length, breadth, or thick- 
ness; or in all at the same time. When the growth is 
markedly forward and the nail is much thickened, it is 
called onychogryphosis. The nail in these instances gen- 
erally turns to one side after reaching a certain length, 
sometimes so much so that a big-toe nail may lie over the 
second and third toes. If the hypertrophy is lateral, we 
are apt to have onychia — ingrowing toe nail. The hyper- 
trophied nail is rugous, but highly polished, brown, and 
there is often an accumulation of scales under it, which at 
times gives rise to a bad odor from decomposition. The 
toe nails are those most often hypertrophied, but the 
finger nails may be so affected. 

Etiology. — Badly fitting boots and neglect of proper 
care of the nails are causes of onychauxis and onycho- 
gryphosis. They often arise without discoverable cause. 
They may be due to a congenital predisposition. They 
very often occur as part of some chronic skin or constitu- 
tional disease, such as eczema, psoriasis, leprosy, syphilis, 
and ichthyosis. The thickening may be due to disease of 
the matrix or to a thickening of the horny layer only. 

Treatment. — The hypertrophied nail may be removed 
by mechanical means, such as by a file, saw, or knife. 
The continued use of salicylic acid sometimes will cause 
the thickened mass to fall off. The oleates of tin and 
lead; the continuous wearing of rubber cots; and liquor 
potassse, are also efficacious in softening the thickened 
mass of the nail. The action of all these agents is as- 
sisted by daily removing the softened layers by mechani- 
cal means. When the hypertrophy is but a part of some 
other disease it will be benefited by the same means as 
will benefit the cause from which it arises. If it is due 
to an inflammatory disease of the nail bed or matrix, that 
must receive attention. (See Onychia and Paronychia.) 
After the nail deformity has been overcome it may return. 



ONYCHIA 485 

Onychia or Onychitis. — By this is meant acute inflamma- 
tion of the matrix of the nail bed. The end of the finger 
or toe, especially about the matrix and nail fold, is red- 
dened and swollen, and there is more or less throbbing 
pain. If unchecked the nail is lifted from its bed, more or 
less pus escapes from underneath it, and it is eventually 
shed. The inflammation often spreads to the adjacent 
parts of the finger, and then we have that condition com- 
monly called whitlow. When the nail falls a spongy 
nail bed is left, often with exuberant granulations. Under 
proper treatment a good nail may be reproduced, though 
in many cases either a very much deformed one will result 
or one that differs somewhat in appearance from the other 
nails. In some cases, instead of this phlegmonous form, 
we have a dry inflammation that is known as onychia sicca 
Here the nail is discolored, its edge thickened and brittle, 
its surface rough and more or less pitted. Eventually the 
nail is shed. This condition is met with most often in 
syphilis. A chronic onychia is occasionally seen, and is 
one of the causes of onychauxis. 

Etiology. — Onychia is due to traumatism or to some 
other disease of the skin, such as syphilis, eczema, psoria- 
sis, parasitic diseases, dermatitis exfoliativa, rheumatism, 
and the strumous state. 

Treatment. — The treatment of onychia varies with 
the stage of the disease and with the cause. Occurring as 
part of some general disease of the skin, the treatment 
appropriate to the general disease will be beneficial to 
the onychia. Arising as an independent disease, or 
resulting from traumatism, the application of a 10 to 
20 per cent, resorcin ointment or plaster, or a 5 to 10 
per cent, salicylic acid ointment, or painting with tincture 
of iodin, will often abort the disease in an early stage. 
The liquor alumeni acetatis kept constantly applied is an 
excellent application. Ichthyol, 25 to' 50 per cent., in 
ointment form, is also useful. Stelwagon advises soaking 
the nail in a warm solution of bicarbonate of soda, 4 (0.26) 
to 5 (0.33) grains to the ounce (32), if the nail is hard 



486 DISEASES OF THE SKIN 

and inelastic; also painting it with a 2 to 5 per cent, 
solution of nitrate of silver in sweet spirits of nitre. If 
the disease has gone on to suppuration, surgical pro- 
cedures will have to be resorted to, such as splitting of 
the nail or its removal as a whole, and subsequent dress- 
ing with iodoform, aristol, or a bichloride solution. 

Onychomycosis. — This term means the invasion of the 
nail by a fungus, such as the trichophyton or achorion. 
For further information see Trichophytosis and Favus. 

Oriental Sore. — See Aleppo boil. 

Osteosis Cutis. — A case of osteosis of the skin of the foot 
was reported by Sherwell 1 in 1892. It involved the 
plantar surface of the left foot about the heel and on the 
fourth toe. The patches were of cartilaginous hardness, 
with horny surfaces studded with nodosities. The patches 
were fairly movable over the underlying parts. They 
were painful when stepped on. The patient was a girl, six 
years old. The patches were excised, but formed again 
within six months. A histological examination by Cole- 
man 2 showed that they contained cancellous bone. 

Paget's Disease of the Nipple.— Synonyms: Mammillaris 
maligna ; Malignant papillary dermatitis ; Epitheliomatose 
eczematoide de la mamella (Besnier). 

Symptoms.— This is a rare disease of the skin that is 
named after Paget, who first described it in 1874. 3 

It usually occurs in women over forty years of age, and 
at first has the appearance of an eczema madidans — that 
is, it presents "a florid, intensely red, raw surface, very 
finely granular, as if the whole thickness of the epidermis 
had been removed. From such a surface, on the whole or 
greater part of the nipple and areola, there is always a 
copious, clear, yellowish, viscid exudation." Besnier 
believes that its primary stage is a keratosis, which, under 

1 Jour. Cutan. and Gen.-Urin. Dis., 1892, x, 119. 

2 Ibid., 1894, xii, 185. 

3 St. Bartholomew's Hospital Reports, vol. x, p. 83. 



PAGET S DISEASE OF THE NIPPLE 487 

any irritation, assumes an eczematous appearance. The 
edge of the patch is sharply defined and slightly raised. 
Sometimes, instead of the raw surface, we have crusting, 
or even scaling. Telangiectases may be seen here and 
there. After months or years marked induration is mani- 
fest, pinching up the patch imparting the sensation, as 
described by Mr. Morris, of "a penny felt through a 
cloth." Burning or itching is complained of, which makes 
the disease the more nearly resemble an eczema. But it 
does not yield to the ordinary treatment of eczema, and 
its border gradually extends. The female breast, usually 
the right one, 1 is the most often affected, and there it 
always begins at the nipple, spreading thence over the 
areola and skin. After a few months, or perhaps not for 
twenty years, signs of scirrhous cancer appear. The 
nipple becomes more and more retracted and ulcerated. 
Shooting pains are complained of. Hard nodules develop 
in the raw surface or deep down in the skin. The mam- 
mary gland itself may become affected. The disease in 
most cases is unilateral. The cancerous cachexia develops 
later with ganglionic enlargements. The disease has 
been reported as occurring on the scrotum, the male 
nipple, glans penis, vulva, axilla, umbilical region, and 
buttocks, but these are exceptional sites. 

Pathology. — It is still an open question whether the 
disease is malignant from the start, or, beginning as a 
simple inflammation, becomes malignant, just as we find 
epithelioma of the tongue developing upon a leukoplakia. 
Later investigations seem to indicate that the process is 
epitheliomatous from the beginning. J. A. Fordyce's 2 
researches show the disease to be an "inflammation of 
the papillary region of the derma leading to oedema and 
vacuolation of the constituent cells of the epidermis, 
followed by their complete destruction in some places 
and abnormal proliferation in others." He holds that the 
disease spreads down the lactiferous ducts from the skin. 

1 Wickham: Maladie de Paget, Paris, 1890. 

2 New York Med. Jour., 1897, lxvi, 445. 



488 DISEASES OF THE SKIN 

O. H. Schultze 1 believes that the disease is not an epi- 
thelioma either as to the skin or the tumor in the breast. 
The latter he finds to be an adeno-carcinoma, but he 
offers no theory to account for the connection between 
malignant papillary dermatitis and the duct carcinoma. 
The changes in the lactiferous ducts are secondary. 

Diagnosis. — Though very important, it is exceedingly 
difficult at first to differentiate positively a case of Paget's 
disease from an eczema. Eczema of the nipple is very 
common during the child-bearing period, while Paget's 
disease occurs most commonly after the climacteric. In 
eczema we do not have, as a rule, the raw granulating 
surface of Paget's disease, while we do have more varia- 
tion in the course of the disease, exacerbations, and seasons 
of apparent quiescence. In eczema the patch is not so 
sharply defined, and its border is not raised ; about it there 
are apt to be outlying pustules or vesicles, and there is 
not the papyrus-like induration. When the nipple be- 
comes retracted and ulcerations take place, together with 
shooting pains and enlarged lymphatics, the diagnosis is 
easy. 

Treatment.— At the beginning, and while the diag- 
nosis is still doubtful, the usual remedies for eczema should 
be tried. If these fail, as they will if the disease is not 
eczema, or if the right diagnosis is arrived at, powerful 
caustics must be used if the disease is still superficial. 
We may use, as recommended by Darier, a solution of 
chloride of zinc, 1 in 3, to produce an exfoliation of the 
diseased epidermis, and follow it with a mercurial plaster, 
alternating with iodoform or aristol. Or a chloride of 
zinc paste may be kept on, spread thickly on lint, for four 
to six hours, and the slough poulticed off or allowed to 
separate under wet boric lint, or under oiled silk, as recom- 
mended by Crocker. Fuchsine in ointment, 1 grain (0.06) 
increased to 5 grains (0.33) to the ounce (32), cured one 
case in Elliot's hands. 

!Jour. Cutan. Dis., 1903, xxi, 201. 



PAPILLOMA 489 

The paste used in the Middlesex Hospital in these 
cases is made as follows: 



1$ — Zinci chlorid., 


5iv 


16 


Liq. opii sed., 


5iv 


16 


Amyli, 


oiss 


6 


Aquse, 


Si 


32 


S. — Ft. pasta. 







M. 



When there is ulceration, but not much induration, the 
surface should be thoroughly curetted and dressed anti- 
septically. When nodules have- formed and there is 
marked induration under an ulcerated surface, the whole 
diseased surface must be freely excised or the breast 
removed entire. In fact, it seems best to amputate 
the breast as soon as the diagnosis is made, when the 
patient is past the child-bearing period. If an operation 
or the use of caustics is inadvisable for any reason, relief 
to the pain and discomfort may be had by dressing w T ith 
a fuchsine solution, 1 per cent, strength. X-rays used 
as in epithelioma have cured some cases, and are always 
indicated in inoperable cases or those refusing operation. 

Panaris Nerveux of Quinquaud belongs to that group 
of obscure diseases in which stand Mor van's disease and 
syringomyelia. It is characterized by swelling of the 
extremities, slight redness, and attacks of intense pain, 
terminating in eight to fifteen days by fissure of the 
finger-end and fall of the nail. Sometimes the skin of 
the finger-end becomes sclerosed and atrophied. 

Brocq advises in its treatment the constant applica- 
tion of chloroform liniment, and of irritant lotions or 
frictions or the galvanic current to the cervical region and 
along the course of the nerves supplying the parts. Inter- 
nally, he advises the valerianate of ammonia or of quinin. 

Papilloma.— By this term is meant a papillary out- 
growth from the skin. Such are common warts, ver- 
rucous eczema, papillary excrescences following ulcera- 
tion, Kaposi's dermatitis papillaris capillitii, ichthyosis 
hystrix, nevus unius later is, and the like. The term is, 
therefore, of uncertain significance. Some authors have 



490 



DISEASES OF THE SKIN 



described papillomata apart from the above-designated 
diseases, and Hardaway reports at length a case of gen- 
eral idiopathic papilloma in a seven-months-old child. 
Mental defects have been noted in some of these cases. 
A mucopurulent secretion often is present, welling up 
between the papillae. The condition is a rare one. Under 
the name of papilloma area elevatum Beigel has described 
one of these rare cases. 

Fig. 71 





Papilloma lineare. (Fox. 1 ) 

Papilloma Lineare. — Called also papilloma neuroticum, 
ichthyosis hystrix, nerve nevus, nevus unius lateris. This 



G. H. Fox, The Skin Diseases of Children, New York, 1897. 



PARAKERATOSIS VARIEGATA 491 

disease is commonly described under ichthyosis. As it 
has no symptom in common with that disease, it is best 
to regard it as a separate disease. It occurs in the form 
of warty, papillary growths that may be isolated though 
grouped, and of pinhead size; or they may be massed 
together into elevated, dark-green plates traversed 
by deep lines; or arranged in long parallel rows. These 
growths may occur on only one side, and in a single 
region; or on both sides of the body and in several regions. 
They sometimes seem to follow the course of nerves 
in their distribution. Pruritus is sometimes complained 
of. While often congenital, they sometimes do not 
develop until a number of years after birth, and all 
tend to increase until early adult life. Their cause is 
undetermined, various theories being advanced to account 
for them. Their arrangement in lines is probably due 
to their occurring along Voight's cleavage lines of the 
skin. The peculiar arrangement of the lesions distin- 
guishes the disease from ordinary warts. 

The treatment consists in scraping away the growths 
with a curette; or picking up the skin into a fold and 
snipping off the top of the ridge with scissors ; or applying 
a 10 to 20 per cent, ointment or plaster of salicylic acid. 

Parakeratosis Scutularis. 1 — Under this name has been 
described a disease that occurred on the scalp of a man 
forty-one years old. The whole scalp, with the exception 
of a strip at the periphery, was covered by a thick, greasy 
crust that enveloped the hair in bundles. Some single 
hairs had on them cuffs of yellowish-white, waxy, horny 
substance, one inch or more long, that were in connection 
with the crusts on the scalp. The growth of the hair 
was not much interfered with. At the edge of the scalp 
was a hairless, red, dry, and rough strip. 

Parakeratosis Variegata. — Synonyms: Dermatitis psori- 
asiformis nodularis; Dermatitis variegata; Erythro- 

1 Internat. Atlas of Rare Skin Diseases, No. 3. 



492 DISEASES OF THE SKIN 

dermie pityriasique en plaques; Lichen variegatus; 
Psoriasiform and lichenoid exanthem. 

Symptoms. — This disease was first described by Unna. 1 
It occurs as a generalized eruption, the face and head 
being often spared, in the form of macules which are 
oval or round and arranged so as to include healthy areas 
of skin in the groups, giving the skin a reticulated appear- 
ance. They vary in size from millet-seed to that of a 
child's palm. The patches are smooth or covered with 
fine, delicate scales. Scattered among them at times are 
flat, pinhead-sized papules w T ith a small scaly centre, 
which soon subside into macules. The general color of 
the eruption is pale lilac, but it may be red, disappearing 
under pressure, or brownish in tint. The patches fade 
in warm weather, but reappear in cold weather. The 
disease is chronic, lasting in spite of treatment for years. 
There is, as a rule, no subjective symptom. There may 
be some itching. 

Diagnosis. — It differs from psoriasis in lacking the 
characteristic scaling of that disease and in the very super- 
ficial character of the patches. It differs from lichen 
planus in its color, in not especially involving the sites 
of lichen, in the absence of itching, and the character 
of its scales. 

Treatment is unavailing. The remedies used in 
psoriasis may be tried, and the x-rays. 

Parasitic Diseases. — The diseases of the skin caused by 
parasites may be divided into two classes: (1) Those due 
to vegetable parasites. (2) Those due to animal parasites. 

Group I comprises favus, ringworm, chromophytosis, 
erythrasma, blastomycosis, granuloma coccidioides, pinta. 
These will be found described under their proper headings. 
In 1899 E. Lusk 2 reported a case whose symptoms re- 
sembled those of scabies, but it was due to mucor corym- 
bifer that was found escaping from the vesicles. 

1 Monatshefte f. prakt. Dermat., 1890, x, 404. 

2 Med. Rec, 1899, lvi, 204. 



PARASITIC DISEASES 493 

Group II comprises a large variety of parasites. Scabies 
and pediculosis, due respectively to the acarus and pedic- 
ulus, are described at length in this book. The brown 
tail moth is referred to under dermatitis and the grain 
mite under acarodermatitis. Besides these we have — 

The leptus autumnalis, harvest bug, or mower's mite, 
that bores its head into the skin, causes great itching, and 
induces violent scratching and consequent excoriations. 

The demodex folliculorum is described in relation with 
the comedo. 

The pulex penetrans, chigoe, or jigger, that resembles a 
flea, but penetrates under the skin with its head, sets up 
inflammation and, perhaps ulceration and gangrene, and 
has to be dug out of the skin with a blunt needle. 

The pulex irritans, or common flea, whose bite causes 
an urticarial eruption in susceptible individuals. It is 
distinguished from that disease by having a hemorrhagic 
spot in the centre of the lesions and in their grouping. 
Powdering the underclothing with insect powder is a pro- 
tection against fleas. Stelwagon recommends the wear- 
ing of a piece of camphor in a small bag under the clothes 
for the same purpose. 

The cimex lectularius, or common bed-bug, attacks the 
skin for its food, punctures it, and at the same time 
injects an irritating fluid to increase the hyperemia and 
the food supply. A wheal, or raised red spot with a central 
puncture, follows the bite, and a purpuric spot results. 
The irritation is relieved by any of the means serviceable- 
in urticaria. 

Gnats and mosquitoes and their effects are all too 
familiar to require extended notice. 

Ixodes, or wood-ticks, the filaria sanguinis and filar ia 
medinensis, the tenia solium, and the echinococcus , all 
find lodgement at times in the human skin. These 
parasites do not exhaust the list, but are the principal ones. 

Dermatobia Noxialis. — This parasite 1 is very prevalent 
in South America, and is the larva of diptera. It con- 

1 E. Costa: Jour. Cutan. Dis., 1910, xxvii, 24. 



494 DISEASES OF THE SKIN 

sists of 11 segments, and measures 7 mm. in width and 
14 mm. in length. It is round; whitish on the back, and 
yellowish-brown on the sides and abdomen. It has 
tentacles on its head, and two strong hooks turned back- 
ward. The same kind of hooks are on all the segments. 
It causes round, soft, elastic, adherent tumors of the 
color of the skin, which may be as large as a mandarin 
or smaller. They present a small opening from which a 
frothy, whitish serum may be squeezed. From these 
tumors the worm can be extracted, after which the 
tumors heal. The application of a 4 per cent, solution 
of carbolic acid will kill the parasites and cure the disease. 
Sarcopsylla Penetrans. 1 — This is an African parasite 
that lives in the soil and penetrates the human skin. 
It is a whitish, globular worm. It causes a swelling of 
the skin, the surface of which looks as if it were covered 
with barnacles. Pain and intolerable itching afflict 
the sufferer. After a while the tumor ulcerates and the 
worm is expelled, leaving a wound with a gangrenous 
margin. The feet are most frequently affected, but the 
disease also occurs on any part of the body surface. 
To cure the trouble, the worm is to be extracted ; mercurial 
ointment forced into the multiple punctures of the skin; 
and the swellings covered with camphorated alcohol. 

Paronychia. — This affection is popularly known as a 
whitlow, run-around, or ingrowing toe nail. Ingrowing 
toe nail results from the nail shoving or being shoved 
into the soft parts, either on account of disease of the nail 
itself, or of ill-fitting shoes, or of injury. The big-toe 
nail at its inner or outer edge, is the most common site 
of the disease, though any toe may be affected. The 
finger nail may suffer, the inflammation being set up by 
some injury or infection. The furrow, fold, and bed of 
the nail all become inflamed, ulcerated, and exquisitely 
tender and painful, the pain being of a throbbing char- 
acter, with the discharge of more or less pus. It is said 

1 E. Costa: Jour. Cutan. Dis., 1910, xxvii, 24. 



PEDICULOSIS 495 

to be more common in young people than in old, and far 
more frequent in men than in women. Paronychia of 
either the ulcerative or non-uleerative form is frequently 
met with in syphilis. 

Treatment. — Severe cases of paronychia most often 
find their way to the surgeon's hands. In syphilitic 
paronychia general antisyphilitic treatment is required. 
In the non-ulcerative form mercurial ointment, diluted 
with one or two parts of diachylon ointment, may be 
used, or the mercurial plaster. The liquor alumeni 
acetatis kept constantly applied is an excellent remedy. 
In the ulcerative form the parts should be cauterized 
with nitric acid or a strong solution of acid nitrate of 
mercury, followed by water dressings. Afterward the 
part may be dressed with iodoform or aristol. Band- 
aging, strapping, with mercurial plaster, and the use of 
rubber cots are also useful methods of treatment. 

In ingrowing toe nail a wedge-shaped piece should be 
cut out of the middle of the free edge of the nail and the 
nail should be filed down the middle, or, if that does not 
relieve the pressure, it may have to be removed in part 
or entire. The insertion of borated lint between the nail 
and the nail fold, or using boric acid in powder first and 
some threads of lint or a little absorbent cotton to separate 
the parts, and strapping the toe with adhesive plaster, will 
also answer well. If ulceration has taken place, the ulcer- 
ated surface should be dressed with iodoform or aristol. 
If the ulceration be covered with exuberant granulations, 
they should be touched with the nitrate of silver stick. 
As a preventive of the trouble, wearing well-fitting shoes 
and keeping the nails clean and cut down the middle are 
the best means at our command. 

Pediculosis. — Synonyms: Phthiriasis; Morbus pedicu- 
laris; Pedicularia; Lousiness. 

Symptoms. — There are three varieties of lice that 
infest the human species, namely, the pediculus capitis, 
pediculus vestimentorum, and pediculus pubis. Though 



496 DISEASES' OF THE SKIN 

they all belong to one family, they differ among them- 
selves, and have distinct regions which they invade. 

The pediculus capitis infests the head only, and of that 
the occipital region and the parts over the ears are the 
common seats of invasion. From these it generally 
spreads to the parietal region, which is one of the best 
places in which to seek for nits, and, maybe, all over the 
scalp. Nits of all species of lice are small pear-shaped 
light yellow or light brown, hard, shiny bodies fastened 
on one side of the hair, from which they are removed 
with difficulty. There are but one or many nits on a 
hair. The lice cause irritation of the scalp both by their 
movements and by the insertion of their haustellum into 
follicles of the skin for feeding purposes. Lice have no 
mandibles. There is no such thing as a louse-bite. They 
simply suck their nutriment by inserting their haustellum 
into the follicles of the skin. The victim scratches to 
relieve the itching and irritation, and this gives rise to a 
dermatitis of eczematous character with the production of 
large pustules. A fully developed and characteristic case 
shows the hair in the occipital region matted together 
with a sticky secretion and, it may be, blood crusts, more 
or less eczematous lesions and large crusted pustules 
scattered over the whole scalp, enlarged lymphatic glands 
in the neck, and perhaps a few small pustules on the neck 
and face. When a patient presents himself with a pustular 
eruption on the back of the neck, or with a number of 
large, crusted pustules scattered over the scalp, pediculosis 
capitis should always be suspected, and search made for 
the pediculi or their nits upon the occipital and parietal 
regions. Very often no pediculi can be found; but if the 
disease is pediculosis, the nits will be discovered in the 
localities mentioned. 

The pediculus vestimentorum, or body-louse, inhabits 
the seams of the clothing, where it lays its eggs, and which 
it leaves only for the purpose of feeding upon the skin. 
It inserts its haustellum into the follicles of the skin, and 
thus produces a small hemorrhagic spot, even with the 



PEDICULOSIS 497 

surface of the skin, which is a pathognomonic lesion of 
the disease. This feeding gives rise to itching, and the 
victim scratches to relieve it, thus producing a second 
symptom, excoriations. These have one peculiarity, which 
is, that they are very apt to take the form of long, parallel 
scratch marks, because the patient digs into his skin with 
all four nails at once. Moreover, as the lice live by prefer- 
ence in the shirt-band at the back of the neck, these long 
scratch marks are most often seen over the shoulders. 
Whenever they are seen we should suspect lice. Excori- 
ations are also seen on the inner or outer side of the limbs in 
locations corresponding to the seams of the clothing and 
about the waist corresponding to the location of the waist- 
band. In certain individuals, besides excoriations and 
hemorrhagic specks, Ave will find ecthymatous pustules, 
ulcerations, and, in very old cases, a great deal of pigmen- 
tation, so that the skin appears as if affected with a general 
chloasma. Any of these symptoms — hemorrhagic specks, 
excoriations, and itching, which is incessant in pronounced 
cases — should lead us to suspect lice, and a careful search 
of the seams of the clothing will reveal them, unless the 
patient has changed everything before coming to us. It 
must be remembered that the lice dwell both in linen and 
woollen clothing, and in bad cases, in the bedding also. 
W. A. Jamieson 1 has found in many cases that the lanugo 
hairs, especially on the back and shoulders, have nits on 
them, and believes that this fact accounts for the relapses 
often seen in the disease. 

The pediculas pubis, crab-louse or morpion, has a far 
wider feeding range than the other varieties. Though its 
favorite habitat is the pubic region, it may be met with 
upon the hair of the abdomen, chest, axillae, beard, eye- 
brows, and eye-lashes. Itching, excoriations, eczematous 
lesions, and nits on the hair are the symptoms it gives rise 
to, though the disturbance is not so great as that caused 
by the other forms of lice. The nits are rounder than 

1 British Jour. Dermat., 1S99, xi, 103. 
32 




498 DISEASES OF THE SKIN 

those of the head-louse and darker in color, sometimes 
looking like small concretions on the hair. It is the 
least common variety. It requires careful search and a 
sharp eye to discover the vermin at times, as they are 
almost transparent, and usually are attached to the hairs 
head downward, and close to the skin. Cobbold taught 
that the pediculus that inhabits the eye-lashes was a dis- 
tinct species, the pediculus palpebrarum; but by most 
authorities the distinction is not made. In some cases, 
instead of red punctate marks, we find dull or slaty-gray, 
or pale-blue, lentil- to split-pea-sized macules scattered 
over the pubes, abdomen, extensor surface of the arms, 
axillae, and inside of the thighs. These are known as 
maculae cerulece, or taches ombrees. They do not disap- 
pear on pressure. They last for a few days, and then 
disappear of themselves. To give rise to these spots there 
must be a predisposition on the part of the skin. Most 
of the few reported cases have been in debilitated sub- 
jects. According to Duguet, 1 the macules are produced 
by the emptying of the contents of the salivary glands 
of the louse beneath the human epidermis. 

Etiology. — These different varieties of pediculosis are 
due to different varieties of lice. The head-louse (Fig. 72) 
is about 2 mm. long and 1 mm. broad, with a triangular 
head and broad thorax and short legs. The body-louse 
(Fig. 73) is larger than the head-louse, being 2 or 3 mm. 
long, with a more oval head and longer legs with more 
developed claws. The pubic louse is broader and flatter 
than either of the others, with rounder head, longer, 
stronger, and more claw-like legs, resembling somewhat 
a crab (Fig. 74). The color of the lice is gray or white. 
They propagate with great rapidity, the young hatching 
out in six or seven days, and being capable within eighteen 
days of propagating their species. It has been calculated 
that two female lice might become the grandmothers of 
10,000 lice in eight weeks' time. The pediculus capitis 

1 Gaz. des Hop., 1880, liii, 362. 



PEDICULOSIS 



499 



deposits its eggs close to the scalp and secretes a glue-like 
substance that sticks the ovum to the hair. There may be 
but a single ovum on a hair, or many of them. The 
distance of the nit from the scalp shows the length of 
time that the disease has existed. As it takes the hair 
about a month to attain the length of three-fourths of 
an inch, if we find the nit that distance from the scalp we 
know that it was deposited at least one month before. 
The severity of the symptoms to which the lice give 
rise will vary with the individual, some people being far 



Fig. 72 



Fig. 73 





Pediculus capitis (male). 
(After Kuchenmeister.) 



Pediculus vestimentorum. 
(After Kuchenmeister.) 



more susceptible than others. Infection takes place 
from other people or from infested body or bed-clothing. 
Women and children are the most frequent victims of 
pediculosis capitis; adults, and especially elderly people, 
of pediculosis vestimentorum. Pediculosis pubis is most 
frequently contracted during sexual intercourse, and is, 
therefore, most common in young adults. Dirt and 
uncleanness favor all forms, though even the most 
cleanly may at times harbor vermin. M. Oppenheim 1 
has found a green coloring matter in the cells of the 

1 Archiv f. Derm. u. Syph., 1901, lvii, 235. 



500 DISEASES OF THE SKIN 

corpus adiposum of the pubic louse, and when these 
pigment-bearing lice are more abundant than the non- 
pigment-bearing ones, the more blue spots or maculae 
cerulese there are. He thinks that the blue color is due 
to the action of a salivary ferment upon the human blood. 
Diagnosis. — Pediculosis capitis needs to be diag- 
nosed from eczema. The characteristic location of its 
lesions upon the occipital region and nape of the neck, 
with its scattered and discrete large pustules over more 
or less of the scalp, should always suggest pediculosis; 

Fig, 74 




Pediculus pubis. (After Schmarda.) 

then if the lice or their ova are found by searching the 
hair, the diagnosis is established. Nits here, as elsewhere, 
are differentiated from epidermic scales by being located 
upon the side of the hair, while the scale has a hair 
passing through its centre (Fig. 74) . The nit, too, is of a 
yellowish color, somewhat pear-shaped, with its larger 
rounded end upward; and it adheres closely to the hair, 
so as not to be readily removed. It is not always easy 
to distinguish pediculosis vestimentorum from pruritus 
cutaneus, especially if at the time the patient presents 
himself he has clean clothes on throughout. Both may 
occur in elderly people, and both may last a long time 



PEDICULOSIS 



501 



^;> t: 



::'.- 



with no other lesion than scratch marks. In pruritus we 
may find evidences of atrophic skin changes; the itching 
is often paroxysmal, and made worse by the patient 
becoming overheated. If we find 
the parallel scratch marks over the Fig. 75 

shoulders and the hemorrhagic 
specks, we can make a positive 
diagnosis of pediculosis. From urti- 
caria pediculosis vestimentorum dif- 
fers in having hemorrhagic specks 
and in the parallel scratch marks. 
Urticaria may complicate a pedicu- 
losis. Scabies differs from pediculo- 
sis in appearing by preference upon 
the anterior face of the wrists, upon 
the breasts in females, upon the penis 
of males, and about the umbilicus of 
both sexes. Its lesions are not long, 
parallel scratch marks, but small 
scratched papules. If the lice of 
their ova can be found in any case, 
the diagnosis of pediculosis is made 
easy. Dermatitis herpetiformis differs 
from pediculosis in wanting the 
parallel scratch marks and in the 
markedly grouped character of its 
lesions. There will often be found 
groups of vesicles scattered about 
the skin. There can be no difficulty 
in diagnosing pediculosis pubis. 
Any itching about the pubic region 
should lead to an investigation, 
which, if carefully made, will reveal 
the pediculi or their nits. 

Treatment. — The most ready means of curing the 
disease when in the hairy regions is to shave the hair off 
and make some emollient application to the scalp to 
cure the eczema. But this is not advisable, excepting in 



Ova of head louse at- 
tached to hair. (After 
Kaposi.) 






502 DISEASES OF THE SKIN 

children and in men in hospitals, and is not necessary. 
The most speedy and practicable method in public 
practice is to soak the hair of the head or pubic region 
with raw petroleum or kerosene, with an equal amount 
of sweet oil. This may be done night and morning for 
two days, and the parts then washed with soap and 
water. This will effectually kill all the lice, and probably 
destroy the life of the ova. The latter must be removed 
for fear that they are not dead, and for this purpose we 
may use a fine-toothed comb to the hair or pull the hair 
through a cloth saturated with vinegar or dilute acetic 
acid, which will soften the glue-like substance of the 
nits. No attention is to be paid to the dermatitis until 
after the cause of it is removed, when it will rapidly 
get well under any simple treatment. In private practice 
an infusion or tincture of delphinium staphisagria (lark- 
spur seeds), or a 10 per cent, solution of carbolic acid, 
or a J to 1 per cent, solution of bichloride of mercury, 
may be substituted for the petroleum. The bichloride 
should not be used if there is much dermatitis. The 
ointment of the ammoniate of mercury is efficient, but, 
as a rule, an ointment should not be used on hairy parts. 
Blue ointment is a well-known remedy for pediculosis 
pubis, but it is apt to set up a dermatitis that is undesir- 
able, and should not be prescribed. Sabouraud advises 
the use of equal parts of compound spirits of ether and 
xylol applied on absorbent cotton. He says it kills the 
lice and the nits instantaneously so that they may be 
easily removed with a comb. 

For pediculosis vestimentorum there is no use in mak- 
ing any application to the skin. The woollen clothes 
should be baked in a hot oven, and the underclothing and 
sheets should be well boiled. If this cannot be done, or 
new clothes obtained, powdered sulphur or delphinium 
may be powdered in all the seams of the clothing, and a 
5 per cent, ointment of carbolic acid applied to the body. 
Jamieson recommends smearing the whole body in all 
cases with vaselin, and then giving a warm carbolic acid 
bath. 



PELLAGRA 503 

Pellagra. — Synonyms: Risipola lombarda; Mai de la 
rosa; Mai roxo; Lombardian leprosy. 

Symptoms. — It has prodromal symptoms of progressive 
weakness, serous diarrhea, lassitude, giddiness, headache, 
and burning sensations in the back, limbs, hands, and feet. 
These make their appearance in the spring, and, shortly 
after, an erythema affects the back of the hands down 
to the articulation of the first and second phalanges, 
the back of the wrists and forearms up to the elbow, 
the back of the feet, if the person goes barefoot, the 
front of the neck and chest to the lower edge of the 
first piece of the sternum, and, in women and children, 
the forehead, nose, and cheeks — that is, all those regions 
exposed to the sun. The palms may be affected. The 
color is bright, dark or livid red, and is not a simple 
erythema, as the color cannot be made to disappear 
completely under pressure. In negroes the skin looks 
as if soot had been sprinkled on it. The skin is often 
so swollen as to prevent all work. Bullae may form upon 
the affected parts and be followed by erosions. In a 
few weeks desquamation begins, but the skin continues 
discolored and thickened up to July or August, when a 
gradual decline of all the symptoms takes place. The 
gums are usually swollen, and the tongue red. There 
may be salivation. During the winter the patient may 
appear quite well, but a relapse is pretty sure to occur 
during the next spring, and to recur each succeeding 
spring with ever-increasing severity of all the symptoms, 
and spread of the eruption; the patient emaciates, loses 
strength, develops grave cerebrospinal neuroses, becomes 
insane, such as dementia or delirium, and after months 
or years sinks into a typhoid state, and dies. The skin 
becomes atrophied, smooth, shining, cracked, or it may 
be thickened. There is a loss of cutaneous sensibility, 
and the erythematous redness gradually extends over 
the whole surface of the body. The average duration 
of the disease is five years, but death may occur in a 
few weeks in acute cases, or not until twenty years in 
the chronic form. 






504 DISEASES OF THE SKIN 

Etiology. — The disease is endemic in northern and 
central Italy, especially in Lombardy, Venetia, and 
iEmilia; in the southwestern part of France, and in the 
northern part of Spain. It may occur anywhere, and is 
growing more and more prevalent in this country, especi- 
ally in the Southern States. Women are most subjected 
to it, children least so. It seems to be a disease fostered 
by poverty, want, an insufficient diet and bad hygiene. 
An almost exclusive diet of decomposed or fermented 
corn, or, possibly, other grains used to be considered as 
the exclusive cause of the disease, but this is now ques- 
tioned, as it occurs in people living in bad hygienic con- 
ditions though not living on corn. J. D. Long 1 thinks 
it may be due to an ameba. Sambone, of Italy, lays it 
to the Buffalo gnat; Roberts 2 is inclined to agree with 
Sambon. Siler, Garrison, and MacNeal 3 think that the 
stable fly is the carrier of the contagion. They found 
the disease to be more prevalent in towns than in the 
country, and in women confined to the house rather 
than in men working in the fields. We still do not know 
the cause of the disease. It is neither contagious nor 
hereditary. 

Pathology. — The liver, kidneys, spleen, and myo- 
cardium show fatty degeneration; ulcers are often found 
in the intestines, and degenerative changes in the brain 
and spinal cord. 

Diagnosis.- — A suspicion of a case being one of pellagra 
should be aroused whenever an erythema upon the 
exposed parts is met with in a person coming from the 
regions in which the disease is known to be endemic, 
especially if it is combined with diarrhea and more or 
less lassitude and hebetude. 

Treatment. — The treatment of the disease is mainly 
hygienic and symptomatic. Crocker has faith in the 
efficacy of arsenic for adults, and frictions with chloride 



i Jour. Amer. Med. Assoc, 1910, lv, 734. 2 Ibid., 1911, lvi, 1713. 

3 Ibid., 1914, lxii, 8. 



PEMPHIGUS 505 

of sodium solution in children. J. D. Long 1 recommends 
enemas of bisulphate of quinin in normal salt solution; 
a diet of milk, toast, rice, and starchy food; pancreatin 
or bicarbonate of soda in capsules coated with phenyl 
salicylate; mercurial inunctions; potassium iodid; daily 
purgation with salts; and rest in bed. H. P. Cole and 
G. J. Winthrop 2 have cured a number of cases by trans- 
fusion of blood from one who has recovered from the 
disease, or who has lived on the same food and in the 
same environment; about 20 c.c. being used. 

Pemphigus. — Synonyms: Pompholyx; (Ger.) Blasen- 
ausschlag. 

A chronic disease of the skin characterized by the 
eruption of successive crops of bullae upon the apparently 
sound skin and with either transient or no antecedent 
erythema. 

At one time every bullous eruption was a pemphigus, 
but with more careful observation and study a number 
of bullous eruptions have been established as distinct 
diseases. Many cases now included under dermatitis 
herpetiformis used to be regarded as pemphigus. It is 
probable that this process of elimination will continue. 
In the meantime a considerable degree of uncertainty 
pervades our knowledge of the disease, both as to its 
symptomatology and etiology, and we can only await 
further developments. While in this attitude we must 
have some sort of a chart to guide us, and it has been 
our object to draw the lines of pemphigus with as great 
sharpness as possible. 

Pemphigus Vulgaris, the form most commonly en- 
countered, may begin with an outbreak of bullae, or 
there may be more or less constitutional disturbance 
before their appearance. The latter condition is more 
often seen in debilitated subjects, children, and old 
people, and consists in chilliness, nausea, and perhaps a 
rise of two or three degrees of temperature. These con- 

1 Jour. Amer. Med. Assoc, 1910, Iv, 754. 2 Ibid., 1910, liv, 1534. 



506 



DISEASES OF THE SKIN 




























































stitutional disturbances may recur before the appearance 
of each crop of bullae. The characteristic eruption is an 
outbreak of two or more up to a hundred or more pin- 
head-sized vesicles that in a few hours develop into tense, 
oval, hemispherical, prominently raised, fully distended 
bullae with translucent contents. The size of the bullae 
varies; it may be but one-eighth of an inch in diameter, 
or by the coalescence of several neighboring bullae, large, 
irregular ones of two or three inches in diameter may be 
formed. One distinguishing feature of these bullae is 
that they have no areola, but spring up at once from the 
seemingly healthy skin. Their contents soon become 
turbid, or perhaps purulent, and then a slight inflam- 
matory halo may form. Hemorrhage into the bullae 
rarely occurs, when it does it is pemphigus hemorrhagica. 
The bullae do not tend to rupture spontaneously, but to 
dry up, and leave the dried cover as a crust. If they are 
ruptured accidentally, an excoriated place is left that 
heals more or less readily, according to the general 
condition of the patient. Some pigmentation may be 
left for a time to mark the site of each bulla. 

The eruption may take place anywhere, but affects 
particularly the lower part of the face, the trunk, and 
limbs. The region of the crotch is a favorite site. It is 
usually bilateral, and may be roughly symmetrical. 
Bullae may occur, in grave cases, in the mouth and 
throat. The life of the individual bulla is two to eight 
days; but while One crop is disappearing a new one occurs, 
and the duration of the disease may thus be measured 
by weeks or months. Sometimes there is an interval of 
weeks or months between the outbreaks. In favorable 
cases a few crops appear, and that is all, the patient 
making a good and complete recovery. In less favorable 
cases, or when the eruption is very extensive, frequent 
relapses and many excoriations take place, the patient's 
strength becomes exhausted by the constant drain upon 
his system and loss of rest on account of the discomfort 
of his condition, and he. may die in a typhoid state, or of 






PEMPHIGUS 507 

some intercurrent affection. A number of cases of death 
from the disease within two or three weeks have been 
reported, and to these the name of acute pemphigus is 
given. A few authorities have reported acute bullous 
eruptions running their course in three to six weeks 
and ending in recovery as acute pemphigus. Many of 
these cases were probably cases of bullous erythema, as 
in them a preceding erythema is noted in the reports 
of the cases. Most cases run a chronic course, extending 
over months or years. 

In rare instances a diphtheritic membrane may form at 
the site of the bulla; or, instead of healing taking place, 
a gangrenous process may be set up, with considerable 
destruction of tissue; or hemorrhage may take place in 
some of the bullae. 

All the mucous membranes may be affected by pemphi- 
gus, and the excoriations that thus form in the mouth add 
greatly to the discomfort of the patient. The conjunctiva 
is not spared, and if attacked serious deformity results. 

Neumann has described as pemphigus vegetans a bullous 
eruption in which healing does not take place, but the 
base becomes covered with sprouting granulations and 
assumes an uneven surface marked by furrows and secret- 
ing a thin fluid. The raw patches thus formed spread 
slowly at their circumference, and neighboring ones 
coalesce. In women the first lesions are usually seen 
about the vulva, and from there the disease spreads 
over the genito-anal region. In all cases the regions 
affected are the axillae, the root of the neck, the hands 
and feet, crotch, elbows, and scalp. It never becomes 
universal. Pigmentation often follows the drying up 
of a bulla. The disease proves progressive; marasmus, 
and, finally, death closes the scene. Most of the cases are 
in syphilitics. 

Cases of pemphigus neonatorum have been reported 
from time to time, and epidemics of it have been de- 
scribed. These are so evidently septic in origin that they 
hardly admit of being classified under the heading of 



508 DISEASES OF THE SKIN 

pemphigus. Careful reading of not a few outbreaks of 
contagious pemphigus reported in the German journals 
will convince one who is acquainted with the bullous 
form of contagious impetigo that a mistake in diagnosis 
had been made by the reporter. Still, until further 
evidence is forthcoming, it is probably advisable to allow 
that both of these varieties of the disease do exist. Pem- 
phigus pruriginosus is another variety made by writers. 
It fits in quite well under Duhring's dermatitis herpeti- 
formis. 

Pemphigus Foliaceus differs considerably from pem- 
phigus vulgaris. Behrend 1 teaches that the difference 
between the two forms is simply a matter of coherence 
between the epidermis and corium, this being so slight 
in pemphigus foliaceus that we have a flaccid bulla 
instead of the tense, fully distended one of pemphigus 
vulgaris. 

Pemphigus foliaceus is the most rare variety of the 
disease, Crocker giving its occurrence as one in five 
thousand cases. It may present its peculiar features from 
the start, or begin as an ordinary pemphigus, or as a super- 
ficial cutaneous oedema, or as dermatitis herpetiformis. 
Its characteristic lesions are flaccid bullae, with opaque 
contents, that soon rupture and leave raw, moist surfaces 
with an edge of ragged epithelium. The fluid of the 
bullae changes its position with the position of the patient, 
always seeking the most dependent part, and soon becomes 
purulent. After the disease has existed some time the 
patient emits a sickening odor on account of the large 
amount of raw surfaces of the ruptured bullae that are 
bathed with sero-pus. Affecting at first only a limited 
space, by degrees the disease spreads so that the whole 
body-surface becomes red and weeping, looking like 
eczema rubrum, with crusts and areas of ragged epithe- 
lium. The palms and soles are often spared on account 
of the thickness of their epidermal coverings. When the 

1 Vierteljahr. f. Dermat. u. Syph., 1879, vi, 191. 



PEMPHIGUS 509 

skin is thus generally involved, it is difficult to establish 
the fact of the occurrence of new bullse. The mucous 
membranes of the mouth and pharynx are affected in like 
manner, becoming converted into raw patches. The hair 
falls out; the nails become thinner, brittle, atrophied, and, 
it may be, drop off; and ectropion is apt to result from 
the contraction of the skin about the eyes. 

The condition of the patient is most deplorable in these 
extensive cases: his skin is stiff and sore, and perhaps 
smarts; and after months or years he succumbs to the 
drain on his system, sinks into a typhoid state, and dies. 

During the early part of the disease there may be no 
constitutional disturbance. But eventually death is quite 
sure to result, if not from the disease, from some inter- 
current affection against which the patient is unable to 
offer any resistance. 

Etiology. — We know very little about the causes of 
pemphigus. The trophoneurotic theory of the disease 
offers us a cloak for our ignorance, and perhaps is, after 
all, the true one. Experiments have demonstrated that 
bullae can be made to form by operations on the spinal 
cord, and observation has shown that bullse do form in 
certain spinal diseases. Both sexes are subject to the 
disease. Children are more often affected than adults. 
The septic origin of certain bullous eruptions has already 
been spoken of under the heading of pemphigus neona- 
torum, and a number of cases of acute pemphigus occur- 
ring in butchers and in those engaged in handling meats 
have been reported by G. Pernet and W. Bullock. 1 
All these ended fatally in a few days. Johnston believes 
that the disease is caused by a toxin developed in the 
internal economy of the individual and finds eosinophilia 
present in marked degree. Bullous eruptions are heredi- 
tary in some families, and in some subjects follow slight 
injuries to the skin. This is named Epidermolysis bul- 
losa, which see. Chilling of the body seems to have been 

1 British Jour. Dermat., 1896, viii, 157. 



510 DISEASES OF THE SKIN 

the exciting causes of some cases. Most subjects of the 
disease are debilitated. Some have advanced the theory 
that an excess of ammonia in the blood or defective 
kidney-elimination is the cause of the disease. Attacks 
of the disease have been observed to occur with each 
new pregnancy in some women. 

Pathology. — "Most authors regard the actual for- 
mation of the bulla as due to an inflammation of the papil- 
lary layer, with outpouring of fluid from the vessels; but 
Auspitz calls it an akantholysis, or loosening of the 
prickle-cell layer, by the sudden escape of fluid from the 
vessels destroying the young prickle cells and lifting up 
the epidermis as a whole. Any inflammatory phenomena, 
he thinks, are secondary." (Crocker.) G. Grinew 1 has 
found in pemphigus foliaceus that the red-blood corpuscles 
are decreased, while the white are slightly increased. 
The size of the blood cells is decreased so that the blood 
is watery. Hemoglobin is decreased as is the specific 
gravity of the blood. The number of lymphocytes is 
lessened, while the leukocytes and eosinophile cells are 
increased. Microorganisms have been found in the fluid 
both of the bullae of chronic and acute pemphigus, and 
a peculiar diplococcus has been demonstrated by several 
observers in apparent causal relation to the disease. 

Diagnosis. — If we regard the pathognomonic symp- 
toms of pemphigus vulgaris as fully distended bullae 
springing up out of the sound skin without any antece- 
dent erythema and without inflammatory halo, and occur- 
ring in crops so as to run a chronic course, then little 
difficulty will arise in diagnosis. A bullous erythema has 
bullae arising upon an erythematous base or with erythe- 
matous lesions elsewhere, and runs a comparatively acute 
course. Dermatitis herpetiformis differs from pemphigus 
in the grouping and multiformity of its lesions, and the 
great amount of itching that attends it. No matter how 
long it has lasted, it is seldom accompanied by the con- 



i Dermat. Zeit., 1904, xi, 



PEMPHIGUS 511 

stitutional disturbances that are met with in pemphigus 
chronicus. In bullous urticaria the bulla rises upon a 
wheal. The bullous syphiloderm occurs usually on the 
palms and soles in infants a few days old, the bullae 
become purulent and form thick crusts, and there are 
present other signs of syphilis. The bullous form of 
impetigo contagiosa will be quite sure to present the char- 
acteristic impetigo pustules upon the hands or face, and 
search will probably discover some child with impetigo 
with whom the patient has come in contact. Varicella 
bullosa occurs epidemically, and runs a short course. 

Pemphigus foliaceus when in its early stage, and affect- 
ing but a small area, is readily diagnosed by the occur- 
rence of its flabby bullse, arising without antecedent 
injury. After it has lasted long enough to involve a 
large area it is with difficulty differentiated from eczema 
rubrum and dermatitis exfoliativa. In fact, without the 
history of the case it is sometimes almost impossible 
to make the diagnosis. It may be differentiated from 
eczema rubrum by its crusts being composed less of dried 
exudation than of epithelium, by the slight amount of 
exudation, by the ragged look of some part of the disease, 
and by careful watching for and finding the large flaccid 
bullse which will be sure to appear if the case is one of 
pemphigus. Moreover, in universal eczema rubrum the 
itching is more pronounced. Dermatitis exfoliativa 
differs from pemphigus in the absence of moisture and 
of bullae, and in the thinness of the exfoliated epidermis. 
Lichen ruber acuminatus is perfectly dry and presents 
characteristic papules. 

Treatment. — The drug upon which most reliance is 
placed in the treatment of this disease is arsenic. We 
may use Fowler's solution; or arsenous acid in pill-form, 
as the tablet triturate with piperina, or the Asiatic pill. 
Whatever form is given, it is advisable to begin with 
small doses and gradually increase them until the limit of 
tolerance is reached or the disease is controlled. Unfor- 
tunately it often disappoints us in its effects. Crocker 



512 DISEASES OF THE SKIN 

regards salicin as almost as valuable as arsenic, given in 
doses of 15 grains (1) three times a day and increased to 
double that amount. Quinin is also valuable either given 
by the mouth in increasing doses up to 30 grains (2) 
during the day, or hypodermically. Attention to diet 
and hygiene, and the general condition of the patient, 
with the judicious use of tonics, such as iron, strychnin, 
and cod-liver oil, will often do as much, if not more, 
than arsenic to cure the patient. 

Locally, dusting powders of oxide of zinc, starch, 
lycopodium, or bismuth in varying combinations; lotions 
of lime-water, borax, zinc, liquor plumbi subacetatis, and 
the like, prove helpful in allaying irritation and discom- 
fort. Lassar's paste is also a good application. Unna 1 
recommends equal parts of linseed oil, lime-water, oxide 
of zinc, and chalk, both to dry up the bullae and prevent 
their return. Linimentum calcis with 1 minim of creo- 
sote to the ounce is recommended by Hardaway. The 
continuous warm bath has afforded great relief in the 
Vienna hospitals. The bullae may be opened if they are 
troublesome. Alkaline and antiseptic mouth- washes will 
afford relief where the mucous membranes are affected. 

Prognosis. — The chances of recovery are uncertain. 
While many cases of pemphigus vulgaris recover, relapses 
are the rule, and if the patient is not strong, or the dis- 
ease has lasted a long time, a guarded prognosis should 
be made. Hemorrhagic, diphtheritic, or f ungating bullae 
are of bad augury. Pemphigus vegetans, pemphigus 
foliaceus, and pemphigus acutus arising from infection 
are almost invariably fatal. 

Perforating Ulcer of the Foot is an accident liable to occur 
in those in whom the nerve supply of the foot is deficient, 
as in locomotor ataxia, syphilis, leprosy, and peripheral 
neuritis. The most common location for the ulcer is 
at the metatarsophalangeal articulation of the great 
or little toe, or the cushion of the great toe. It may be 

1 Monatshefte f. prakt. Dermat., 1888, vii, 108. 



PERIFOLLICULITIS SUPPURATIVA 513 

only on one foot, or both feet may be affected. The 
process is slow, beginning as a proliferation of the epi- 
dermis like a corn, under which suppuration takes place, 
and an ulcer is left. This goes deeper into the tissues, 
until a sinus forms that reaches to the bone. The edges 
of the ulcer are hard. The external opening is often 
smaller than the sinus below. Usually there is little 
pain, though there may be hyperesthesia of the sur- 
rounding parts, and attacks of inflammation at times. 
This painlessness distinguishes it from a suppurating 
corn. The palms may be affected in the same way as the 
soles. The disease is very intractable, and must be 
managed on surgical principles, amputation of the whole 
or part of the foot being required in some cases. Death 
may result from the disease. 

Under the name of Hand-and-foot Disease, Hyde 
reported 1 three cases of ulcerations of the hands and feet 
that he regarded as due to trophoneurotic disturbances. 
In these cases, with or without functional disturbances, 
such as hyperidrosis and coldness of the hands and feet, 
bromidrosis, local anesthesia, vertigo, faintness, and 
rheumatic pains, there were found various grades of 
dystrophia unguium, from roughness to onychogry- 
phosis, tender and painful or insensitive maculations 
of the hands and feet, or both; different dermatoses, 
such as erythema, eczema, ichthyosis, local alopecia 
hypertrichosis, symmetrical tylosis, with or without 
spontaneous exfoliation or recurrence. After a time 
ulcerations formed on the hands or feet, or on both 
hands and feet. 

Perifolliculitis Suppurativa Conglomerata. — Under this 
title Leloir 2 has described and figured a rare disease of 
the skin which especially affects the back of the hands. 

Symptoms. — It seems to commence as a diffused red 
patch upon which develop small pustules, which itch 
slightly; or as small, red, more or less conglomerate, 

1 Philadelphia Med. News, 1887, li, 416. 

2 Ann. de derm, et de syph., 1884, v, 437. 
33 



514 DISEASES OF THE SKIN 

slightly itching elevations that form patches. The patches, 
however formed, are sharply defined, raised from 2 to 5 
mm., round or oval, flattened, and of red, vinous, viola- 
ceous, or blue color. They vary in size from that of a 
ten-cent piece to that of a silver dollar, and are often 
crusted. When the crust is removed, the exposed surface 
is smooth or mammillated, but never papillomatous; 
and riddled with a number of pinpoint to pinhead- 
sized openings, corresponding to glandular orifices, 
many of which are closed with a plug of greenish, dried 
pus. Beside these openings there are a number of green- 
ish points that are ready to become such whenever the 
epidermis over them is removed. At a more advanced 
stage the openings form small pinhead-sized ulcers. By 
compression of the patch these openings give vent either 
to a drop of pus or serous fluid, or little, elongated, 
vermicelli-like whitish masses. In still more advanced 
cases the patches become more elevated, fluctuation 
manifests itself, and sero-pus may be expressed. The 
patches are usually single, but may be multiple. The 
back of the hand and wrist are the usual locations of the 
disease; but it may occur upon the dorsum of the foot 
or the outer side of the thigh, or be disseminated, but 
chiefly located on the extremities. The course of the 
disease is acute. It is fully developed in eight days; 
it then continues a week or two and disappears in about 
twelve days more. If badly treated, it may last longer, 
and be followed by a papillary condition. It is unattended 
by subjective symptoms, except slight itching. It leaves 
either no trace of itself, or a delicate superficial cicatrix 
that disappears, or a slight staining that soon fades. 
The hair is unaffected, though the disease may involve 
its follicles. 

Pathology. — The disease is a purulent inflammation 
of the skin follicles, especially of the lanugo hairs, and the 
pilo-sebaceous follicles of regions deficient in true hairs. 
It is possibly microbic in origin. Crocker regarded it as 
a form of ringworm. 



PERNIO 515 

Diagnosis. — The disease is diagnosed from trichophy- 
tosis by its more rapid course, and recovery under sim- 
ple treatment; by the hair being unaffected; and by the 
absence of the trichophyton in the hair. Anthrax differs 
from it in the more pronounced character of its local and 
general reaction, its central core, and inflammatory indu- 
ration. Tuberculosis verrucosa cutis is much slower in its 
evolution, is serpiginous, and does not yield to simple 
treatment. Eczema differs from it in not having such 
sharply marked borders; in wanting the characteristic 
openings and livid tint; and in having more pronounced 
itching, a mucous, sticky discharge, and a comparatively 
long duration. 

Treatment. — The treatment is simple and consists in 
squeezing out the pus once a day, bathing the part for 
half an hour in warm carbolized water on a solution of 
boric acid, and covering with an antiseptic dressing. If 
papillae have formed, they should be scraped off, and the 
surface touched with nitrate of silver. In some obsti- 
nate cases it may be necessary to scrape out the whole 
patch. 

Perleche. — According to Brocq, this is a disease occur- 
ring in infants and affecting the commissures of the lips. 
Their epithelium is pale, macerated, desquamating, while 
the skin underneath is red and slightly inflamed. Some- 
times fissures will form that are painful, and may bleed 
when the patient opens his mouth wide. The inflam- 
mation may spread to the neighboring regions. It runs 
a course of two or three weeks, but is subject to relapse. 
It is contagious, and is due to a streptococcus. 

It bears a close resemblance to the fissures of the lip 
met with in syphilis, but is marked by an absence of all 
other symptoms of syphilis. 

The treatment consists in touching the diseased parts 
with sulphate of copper or alum, or an antiseptic solution, 
and in carefully looking after the nursing-bottles. 

Pernio. — See Dermatitis calorica. 



516 DISEASES OF THE SKIN 

Phagmesis. — A rare condition in which it is said that 
feathers instead of hair adorn the body. 

Phtheiriasis. — See Pediculosis. 

Piedra. — Synonyms: Tinea nodosa; Trichomycosis 
nodosa. 

Symptoms. — There are two varieties of this disease, 
Piedra and Piedra nostras. 

Piedra occurs in Cauca, one of the United States of 
Colombia, and was first described in 1874 by Dr. N. 
Osorio, of the University of Bogota, but may occur else- 
where. It consists in the occurrence along the shaft of 
the hair of from one to ten small dark-colored nodes 
which are very hard and gritty, and rattle like stones 
when the hair is combed or shaken. The stony hardness 
of the nodes gave the disease its name "Piedra," which 
is the Spanish for "stone." These nodes are always 
placed at irregular intervals along the hair-shaft, begin- 
ning at about half an inch from the point of exit of the 
hair, the root being unaffected. The disease occurs most 
commonly in women, men being rarely affected, and it is 
the head-hair alone which exhibits these nodes. The 
disease is non-contagious, and is met with only in warm 
valleys. 

Piedra nostras consists in the presence of hard, smooth, 
poppy-seed-like nodes and elongated sheaths of brown 
color upon the hair of the beard and moustache. They 
are from 2 to 12 mm. long, and about twice the thickness 
of the hair upon which they are attached. The hairs 
are unaltered. 

Etiology. — Dr. Osorio thought that the nodes in 
Piedra were produced by an agglomeration of epithelium 
in certain parts of the hair. Mr. Morris 1 believes it is 
due to the use of a peculiar mucilaginous linseed-like 
oil, which is used particularly by the native women to 
keep their hair smooth and shiny. Another theory is 
that it is due to the use of water of certain stagnant 

1 Lancet, 1879, v 407. 



PINTA 517 

rivers which is very mucilaginous. Heat seems essential 
for its production, as the employment of either of these 
fluids will not cause the disease in cold climates. 

Microscopic examination of the affected hair shows 
that the nodes consist of a honeycombed mass of pig- 
mented spore-like bodies, the whole mass arising from 
one cell which sends out spore-like columns radially in 
all directions. As soon as the cells have reached a certain 
size they seem to alter their shape, become darker in 
color, and form a psuedo-epidermis. It is, therefore, a 
fungous growth. The nodes were found to be very hard 
to cut, and when considerable force w T as used they broke. 

The cause of Piedra nostras is a fungus growth. 

Diagnosis. — Piedra differs from trichorrhexis nodosa, 
in the stony hardness of the nodes, in its occurring prin- 
cipally upon the head-hair, in its probable etiology, and 
in the microscopical appearances it presents. Piedra 
nostras differs from Piedra by its nodes being larger, 
and by occurring on the hair of the beard. 

Treatment. — -By the use of hot water the nodes can 
be entirely removed. 

Pimples. — See Acne. 

Pinta. — Synonyms: Mai de los pintos; Tinna; Caraate 
or cute; Quirica; Spotted sickness. 

This disease occurs in the Philippines, southern Mexico, 
Panama, and South America. 

Symptoms. — According to Crocker, from whose work 
this account is drawn, it consists of scaly spots varying 
in color, shape, number, and size. They show themselves 
first on the uncovered parts, but may affect any and all of 
the cutaneous surface. The disease spreads by the periph- 
eral extension of old patches and the formation of new 
ones. The patches are round or irregular in shape, 
sharply or ill-defined, and of black, gray, blue, red, or 
dull-white color. The red and white patches are deeper- 
seated than the others, being located in the rete and 
corium. The patches may be of uniform color, or of 



518 DISEASES OF THE SKIN 

different tint, but do not change their color after they 
have once formed. They are scaly and usually feel rough 
and dry. The hair grows gray and falls. There is some 
itching, and a bad odor emanates from the patient. The 
course of the disease is chronic and shows no tendency 
to recovery. 

Etiology.— The disease is contagious, and its spread is 
favored by dirt and neglect. It is most common in the 
poor natives of Indian stock. It is of fungous origin, 
and, in fact, seems to be allied to chromophytosis. 

Treatment. — The treatment is the same as for chro- 
mophytosis and ringworm. 

Pityriasis Alba Atrophicans. — This disease begins in 
early life as a partly lamellar, partly branny desquama- 
tion of the skin without redness or any other form of 
efflorescence. The skin may be affected wholly or in 
part. After lasting ten to fifteen years it is followed by 
secondary atrophy of the skin, which becomes thinner, 
and softer. The subcutaneous fat is lost and the veins 
show through. 

Pityriasis Capitis. — There are two forms of this disease, 
pityriasis simplex and pityriasis steatoides. Scaling 
of the scalp is physiological if of so moderate a degree 
as to be unnoticeable. If of more intense degree it 
constitutes a disease. 

Pityriasis Simplex Capitis. — Synonyms: Dandruff; 
Seborrhea sicca (Hebra). 

Symptoms. — The hair is usually dry and lusterless, 
with white or gray scales scattered through it, giving 
it a powdery appearance. The amount of scaling may be 
so great that the collar of the coat or dress is covered with 
them. This is what is called dandruff. The scalp is 
covered with the scales, beneath which it is dull white 
in color. There may be areas of the scalp of normal 
appearance. The scalp itches, and may show signs of 
having been scratched. 



PITYRIASIS STEATOIDES 519 

Etiology. — While the disease may occur in children, 
most cases begin at or about the age of puberty. It is 
more frequent in men than in women. All things that 
lower the nutrition of the subject tends to aggravate 
the disease. It is probably due to the infection of the 
scalp by the spores of Malassez, which are the same as 
the bottle bacillus of Unna. 

Diagnosis. — It differs from ring worm in not causing 
thinning of the hair, in the absence of stumps, and the 
spores and mycelia of that disease. Chronic squamous 
eczema is more pruritic, often extends beyond the hair 
line, and shows evidence of inflammation. In psoriasis 
the patches are more sharply defined, of red color, more 
thickly covered with heaped-up scales, and typical patches 
of the disease will be found elsewhere on the body. 

Pityriasis Steatoides. — Synonyms: Seborrhea sicca; 
Eczema seborrhoicum. 

Symptoms. — The scalp is covered with scales of a 
yellow or amber color, often heaped up into crusts. 
They are distinctly greasy to the feel. They adhere 
more or less closely to the scalp. ' They are often very 
abundant. The scalp may be of normal color, or slightly 
rosy with a glistening surface. The whole scalp is usually 
affected, and exceptionally the disease may go over 
beyond the border of the hair. The scalp itches. After 
a time the hair begins to fall. 

The process is often associated with seborrhea and 
pityriasis simplex. The disease not infrequently passes 
over into a seborrheal dermatitis or an eczema may 
develop. 

Etiology. — This form of pityriasis is due to infection 
of the scalp with Sabouraud's polymorphous coccus with 
gray culture. It is usually secondary to pityriasis simplex, 
and seems to be the result of a double infection with the 
spores of Malassez and the just mentioned coccus. Both 
sexes are affected. It begins most often between the 
twentieth and thirtieth year of age. It is rather more 



520 



DISEASES OF THE SKIN 



frequent among the poorer classes. The barber shop, 
is a very common spreader of contagion. 

Dia gnosis. — In seborrhea we have the so-called fila- 
ments, and the presence of the microbacillus. In sebor- 
rheal dermatitis there is redness and swelling of the scalp, 
and a tendency of the disease to involve many different 
parts of the body. In eczema the signs of inflammation 
are marked, a sticky exudation is often in evidence, the 
disease is more patchy, and the itching more marked. 
In psoriasis the scales are not greasy, the patches are 
sharply defined, and characteristic lesions of the disease 
are found scattered over the body. 

Treatment. — The treatment of both forms of pity- 
riasis is practically the same. The most efficient remedies 
are antiparasitics, such as sulphur, mercury, resorcin, 
and tar. When the scalp is dry and scaly it is best to 
exhibit our remedy in the form of an ointment. If the 
scales are greasy and the hair oily, then alcoholic com- 
pounds are better. In many cases it is best to use a lotion 
for a few days until the scalp becomes drier, and then 
an ointment. It must be kept in mind that a sulphur 
preparation is not to be used alternately with one con- 
taining mercury, as a black sulphide may form which is 
annoying to the patient. While any application is being 
made to the scalp, the latter should be washed at least 
every two weeks. The formula that are useful in pity- 
riasis are given in the section on alopecia pityroides, to 
which the reader is referred. 

Prognosis. — Both forms of pityriasis are chronic. 
Complete recovery in which no relapses occur are rare. 
The simple form is said not to be followed by loss of 
hair, but as in most cases it develops into the steatoid 
form, which always causes baldness, alopecia may be 
stated to be the end result of the disease unless it is kept 
in check. By continued judicious care of the scalp the 
hair may be indefinitely preserved. 

Pityriasis Lichenoides Chronica. — See Parakeratosis varie- 
gata. 



PITYRIASIS ROSEA 521 

Pityriasis Maculata et Circinata. — See Pityriasis rosea. 
Pityriasis Pilaris. — See Keratosis pilaris. 

Pityriasis Rosea. — Synonyms: Pityriasis maculata et 
circinata; Herpes tonsurans maculosus (Hebra); Roseola 
pityriasiaca (Barduzzi); Pityriasis circine et margine 
(Vidal); Pityriasis rosee (Gibert); Erytheme papuleux 
desquamatif. 

An acute disease of the skin characterized by an 
eruption of rosy-red macules that enlarge into dry, 
scaly, oval or annular patches with rosy-red peripheries 
and chamois-yellow, wrinkled centres; it runs a definite 
course and terminates in recovery. 

Symptoms. — The outbreak of the disease may be pre- 
ceded by slight constitutional disturbances, such as 
malaise, loss of appetite, and headache, with a slight 
rise of temperature just before the outbreak of the 
eruption. Crocker says that there is often enlargement 
of the post-sternomastoid and submaxillary glands, and 
maybe other glands. The eruption itself most often 
begins without prodromas upon the upper part of the 
chest, a little above the breasts, or, according to Brocq, 1 
at the level of the waist-band, anteriorly and a little to 
one side, where he locates what he calls the "primitive 
patch." The primary lesions are miliary or small papules 
of pale-red color, surrounded by an erythematous zone. 
These soon enlarge into rosy-red, slightly raised macules, 
and slowly increase peripherally into oval or rounded 
patches with well-defined borders raised somewhat higher 
than the centres. When the patches have attained a 
diameter of half an inch or more the centres begin to 
clear up by becoming of a yellow, old-parchment color, 
scaly and shiny, while the border is pale red. Later 
the centre may disappear and rings only remain; or if 
two or more patches meet at their borders, irregular 
gyrate figures may be formed. All the lesions do not 
attain the same degree of development, and in well- 

1 Ann. de derm, et de syph., 1887, viii, 615. 



522 



DISEASES OF THE SKIN 



developed cases lesions in all stages will be found. The 
lesions are slightly scaly from the commencement and 
the furfuraceous desquamation continues until the faint 
mark left by the lesion disappears. Itching, usually 
slight in amount, and only when the person is warm, 
is the only subjective symptom. Sometimes it is severe. 
The eruption is most marked upon the neck, infra- and 
supraclavicular regions, sides of the chest, and shoulders; 
it may be marked also on the abdomen and buttocks. 
The whole body may be involved, but the hands and 
feet are usually spared, and it is uncommon on the face. 
After some three to six weeks the disease tends to spon- 
taneous recovery, although it may last for months. 



Fig. 76 




Pityriasis rosea. By the courtesy of Dr. S. I. Rainforth. 

Etiology. — We know nothing about the cause of the 
disease. It affects all ages and both sexes. Crocker 
finds that one-third of the cases are in children. Most 
of the cases we have seen have been in young adults. 
This difference may be accounted for by the fact that he 
has a large children's dispensary service. Some cases 
seem to be due to overheating of the skin by wearing 



PITYRIASIS ROSEA 523 

too heavy underclothing. Hyde and Montgomery teach 
that it occurs most often in blond subjects who have 
been enfeebled by great physical fatigue or overstudy 
in school. The disease seems to occur epidemically in 
some instances, and cases are apt to present themselves 
in groups. Contagion has not been established. Bazin 
regards it as arthritic. It may be parasitic, but as 
yet the parasite awaits demonstration. Vidal 1 describes 
a parasite that he names the microsporon anomen, as 
found in pityriasis circine et margine, which is the same 
disease. Hebra regarded it as a manifestation of tricho- 
phytosis, and some authorities still think that some cases 
are diffused ringworm. There is a strong probability that 
it is due to a toxin developing in the intestinal tract. 

Pathology. — The process is a mild inflammation in 
the upper cutis, more marked toward the periphery of 
the lesions. In the more pronounced cases minute 
vesicles, visible only microscopically, are found beneath 
the corneous layer. 

Diagnosis. — Pityriasis rosea must be differentiated 
from the early circinate, scaling, macular syphiloderm; 
annular psoriasis ; seborrheal dermatitis ; and disseminated 
trichophytosis. The one most distinguishing feature of 
pityriasis rosea is the wrinkled old-parchment yellow of 
the centre of the ring. This is absent from the lesions 
of all the other diseases with which it is likely to be 
confounded. The syphilid is of a less bright-red color, 
and there surely will be some other evidence of syphilis to 
guide us. Psoriasis is far more scaly; the scales are of 
a white color; the tips of the elbows and the anterior 
face of the knees will be especially affected; and typical 
psoriatic patches will be found somewhere. Seborrheal 
dermatitis occurs upon the middle sternal and inter- 
scapular regions particularly; the patches have a greasy 
feel; the scales are thicker than in pityriasis rosea; the 
papular lesions are more raised and evidently in relation 

1 Ann. do derm, et de syph., 1882, iii, 22. 



524 



DISEASES OF THE SKIN 



to a follicle of the skin ; and the lesions show little tendency 
to spontaneous involution. Cases occur in which it is 
very difficult to make the diagnosis between this and 
pityriasis rosea. In trichophytosis the fungus is readily 
found under the microscope, which is a decisive test. 
Apart from that, ringworm does not spread so rapidly 
nor involve such wide areas. Measles differs from it by 
having catarrhal and constitutional symptoms, and by the 
absence of the rings with old parchment-like centres. 

Treatment. — Pityriasis rosea is a self-limited dis- 
ease, and recovery is sure to take place in a short space 
of time, usually from three to six weeks. Though treat- 
ment seems not to have any marked effect on the dis- 
ease, we may use lotions of salicylic acid, 10 to 20 grains 
(0.66 to 1.33) to the ounce (32), or of boric acid; or con- 
tent ourselves by allaying the itching with lotions of 
carbolic acid 10 (0.66) grains to the ounce (32), calamin, 
oxide of zinc, and the like. Tepid alkaline or bran baths 
may be used, followed by a dusting powder. Crocker 
has faith in salicin in the dosage of 15 grains (1) three 
times a day. 

Pityriasis Rubra. — See Dermatitis exfoliativa. 

Pityriasis Rubra Pilaris. — This name was first given by 
French writers to a disease that had been known for a 
long time as lichen ruber, and was first described by 
Hebra. It has driven the earlier name out of the field, 
unjustly as we think. 

Symptoms. — A typical case has three principal ele- 
ments: (1) Asperities of the follicular orifices; (2) Desqua- 
mation; (3) Roughness of the skin with exaggeration 
of its folds. The disease generally begins suddenly, 
without prodroma, but there may be some malaise 
nervousness, insomnia, hyperesthesia of the finger ends, 
formication, and the like. These prodromas are of short 
duration, and rarely cause the patient to go to bed. 
The uncovered parts are usually first affected with the 
eruption, but it may appear primarily upon the trunk 



PITYRIASIS RUBRA PILARIS 525 

or extremities. The initial lesion may be a simple exfolia- 
tion; an erythema; a scaling erythema; a fine but scanty 
furfuraceous desquamation; a shiny redness with pityriasis; 
desquamation of nail bed, or fragility of nail. However 
beginning, the more pronounced form appears in a certain 
number of days or weeks, and may develop or abort at 
any point, or be limited to any region, or involve the 
whole body. When fully developed, a patch or the whole 
skin, as the case may be, presents the following character- 
istics: It is covered with elevations that are generally 
conical, but may present great diversity of shape. They 
may be discrete or coalesce. They may be so small as to 
be seen only by the aid of a microscope, or elevated many 
millimeters above the surface, with corresponding diam- 
eter. They are scaly, and vary in color from a silver 
white or gray to a bright or opaque red, red brown, 
or rosy yellow. Their summits may be flat, uneven, 
cone-shaped, or truncated, giving issue to a hair broken 
off at a little distance above the surface of the skin, and, 
it may be, sheathed by a corneous or sebaceo-squamous 
case. Instead of a hair protruding, it may form only a 
small comedo-like spot at the centre of the summit, or 
it may be wanting, or it may seem to exist alone, giving 
to the region the appearance of a badly shaven beard. 
Sometimes the cone presents a crater, at the bottom of 
which is a black point, a punctured scaly plate, or a 
psoriatic point. Patches are formed by the coalescence 
of the papules. They are fairly well defined, of all 
shapes, scaly, grayish in color, rough to the touch, and 
bear a resemblance to chagreen leather. Scattered about 
the usual papules will be found. The patches are very 
capricious, coming and going. The skin is scaly, dry, 
hard, rough like a file, and presents a "goose-skin" 
appearance. The scales may be scraped off without any 
loss of blood. 

The disease is generally symmetrical, but the lesions 
may be disseminated without order, or in irregular lines, 
groups, or islands, or may unite in tessellated areas. 



526 DISEASES OF THE SKIN 

The cone-like elevations do not occur on the scalp, and 
are rare on the soles and palms. In these locations 
the disease takes the form of abundant desquamation 
upon a reddened base. When the face is attacked the 
skin is dry, red, scaly, and thickened. All other regions 
may be affected, the cones forming about the follicles 
of the skin, especially about the hair follicles. The back 
of the phalanges of the fingers are nearly always affected, 
appearing rough, uneven, and covered with patches of 
characteristic papules. This appearance of the back of 
the phalanges is one diagnostic mark of the disease. A 
favorite site is the upper part of the inter natal furrow. 
In very severe cases nearly all the surface is involved. 
Some variations from the type are encountered in different 
regions, but characteristic types will be found somewhere 
on the body. The hair may fall, and the nails may be 
deformed, opaque, and raised by an accumulation of 
scales under them. 

The general condition is unaltered, and little, if any, 
discomfort is experienced. The duration of the disease 
is indefinite. It may disappear entirely or completely. 
Relapses are the rule. Second and subsequent attacks 
may be shorter than the first. 

Etiology. — The etiology of the disease is obscure. It 
is rarely met with. It occurs at all ages, and in both 
sexes, but most often in infancy or youth, and in males. 
Many causes have been assigned to it, such as cold, 
excesses, rheumatism; but none of these can be definitely 
said to be the cause. 

Pathology. — The essential change is a hyperkeratosis 
in the epithelial lining of the orifice of the hair follicle. 
All the layers of the epidermis are much thickened. 
Secondary inflammation occurs in the upper part of the 
derma. 

Diagnosis. — The disease is to be diagnosed from 
ichthyosis in not being congenital; in attacking by pre- 
ference the joints, scalp, face, and neck; and in its spon- 
taneous recovery for a time. From dermatitis exfoliativa 



PLICA POLONICA 527 

by its benign course; its location about the follicular 
openings; and by the thick scaling of the palms and soles. 
Lichen planus presents angular, flat, umbilicated papules 
of peculiar violaceous color, is very pruritic, and usually 
spares the face and backs of the phalanges of the hands. 

Psoriasis at times bears a strong resemblance to pity- 
riasis rubra pilaris, but it seeks the elbows and knees 
particularly; its scales are larger; and it is not a follicular 
disease, never presenting comedo-like plugs, broken-off 
hairs, or little elevations. 

Tkeatment. — No satisfactory treatment has been 
found. Arsenic may be given. The general health of 
the patient must be cared for. Locally the remedies 
applicable to psoriasis or to ichthyosis can be used with 
advantage. Like in that disease, an attack may be over- 
come, but no assurance can be given against a relapse. 
Thus far no fatal case has been reported, though Hebra's 
cases of lichen ruber were commonly fatal. 

Pityriasis Simplex. — See Pityriasis capitis. 

Pityriasis Tabescentium is that condition occurring in 
marasmic individuals where there is scaling of the whole 
skin especially marked on the extensor surfaces of the 
extremities and trunk. 

Pityriasis Versicolor. — See Chromophytosis. 

Plica Polonica. — Synonyms: Trichosis plica; Trichoma; 
(Pol.) Koltun; (Ger.) Weichselzopf; (Fr.) Plique polo- 
naise; Polish ringworm. 

Symptoms. — This is rather a condition than a disease, 
in which the hairs of the head and other parts become 
matted together into variously shaped masses, on which 
rest all sorts of extraneous matters deposited from the 
air; and in which are harbored vast hordes of pediculi. 
Sometimes these matted tresses are near the scalp, and 
sometimes far away. Not infrequently an oozing eczema 
of the scalp will be found. The masses will assume all 
sorts of shapes, to which various names have been applied . 



528 



DISEASES OF THE SKIN 



An offensive odor often emanates from the scalp. Occur- 
ring among ignorant people, as is usually the case, these 



Fig. 7 r , 



ifli HP 1 


•V 


- mwa 




m 


1 



Neuropathic plica. (Stelwagon.) 



plicas are regarded with superstition. The patient and 
friends refuse to have them cut off lest some dire disease 
befalhthe bearer. 



POMPHOLYX 529 

Under the name of Plica Neuropathica a few cases of 
matting of the hair into masses like those in plica polonica 
have been reported as occurring in cleanly individuals. 

Etiology. — The cause of the condition is want of 
cleanliness combined with an oozing dermatitis of the 
scalp due to pediculi or any other cause. Plica neuro- 
pathica seems to be due to a peculiarity of the hair 
causing it to felt. 

Treatment. — The treatment consists in the liberal use 
of soap and water, and curing the dermatitis. If allowed, 
the most effective way of beginning treatment is to cut off 
the hair. The patient must be instructed in hygiene of 
the scalp. 

Pompholyx. — Synonyms: Dysidrosis; Cheiro-pompholyx. 

Symptoms. — The first thing that the patient notices is 
a burning and itching of the palms or soles, and sides of 
the fingers or toes In a few hours small, clear, sago-grain- 
like vesicles, sometimes grouped, and with an erythema- 
tous zone about them, appear in these locations. They 
are often very numerous, and some of them run together 
to form small and large bullae. Their contents are at 
first clear and neutral; later they become turbid and have 
an alkaline reaction. These \ T esicles do not tend to spon- 
taneous rupture. In a few days they dry up, their 
covers fall, and large and small, dry, red surfaces are 
left to mark their locations. If the lesions have been 
very numerous, the whole of the old skin may be shed. 
In slight cases the palms or soles will be dotted over with 
irregularly shaped red spots with ragged edges. As a 
rule, the backs of the hands and feet are unaffected, 
though the rule has many exceptions. It is usually 
symmetrical or bilateral. Abortive attacks are quite 
common in which the disease is limited to two or three 
lesions on the side of one or more fingers. The sub- 
jective symptom is burning, though itching may occur. 
The patients are seldom in perfect health, and are usually 
nervously depressed. Hyperidrosis of the affected parts 

34 



530 



DISEASES OF THE SKIN 



commonly accompanies or precedes the outbreak, and 
sometimes a lichen tropicus will be found on the trunk. 
The duration of the attack varies from a few days to 
three or four weeks, and relapses in the same or follow- 
ing years are common. Most all cases are seen in the 
summer. It is usually symmetrical, though one side may 
be affected before the other. Some systematic writers 
regard the disease as an eczema. 

Etiology. — Over the causes of the disease there has 
been and still is active discussion. It seems to be in 
some way connected with the sweat glands, but whether 
it is a simple impediment to the escape of the sweat or 
an inflammatory disease is not determined. Some able 
pathologists ally the disease to herpes, and deny any 
connection with the sweat glands. Occurrence of the 
disease in hot weather points to the sweat apparatus 
being at fault. There is probably a vasomotor 
neurosis at the bottom of the trouble. It affects all ages 
and both sexes, though most common in young adult 
women, and in those who are of nervous temperament 
or the subjects of worry and over-fatigue. It is said 
that organic or functional heart disease is the cause of 
some cases. Unna states that he has found constantly a 
bacillus in sections of the vesicles. 

Pathology. — Robinson, who has carefully studied this 
disease, regards it as a neurosis allied to herpes and 
pemphigus. He thinks it has nothing to do with the 
sweat glands, but that it is inflammatory. The contents 
of the vesicles, he shows, is not sweat, but serum; and the 
reaction of the fluid is alkaline or neutral in its early 
stages, never acid. It also contains a large amount of 
albumin and some fibrin. It comes from the papillary 
bloodvessels, and passing between the rete cells collects 
in different situations in the stratum mucosum. 

Diagnosis. — Pompholyx must be differentiated from 
eczema, scabies, pemphigus, and erythema bullosum. It 
differs from eczema in its vesicles not tending to break 
down of themselves; in not presenting a moist surface 



POROKERA TO SIS 531 

after the vesicle tops fall ; and in running a more definite 
course. The sago-grain-like appearance of the vesicles is 
not peculiar to it, as it is frequently seen in eczema of the 
hands, and is due to the thickness of the epithelium, 
preventing the ready escape of the fluid. Scabies may 
bear a close resemblance to pompholyx but can be readily 
differentiated by finding the burrows, and noting the 
location of the eruption upon the anterior surface of the 
wrists, the breasts in women, the genitals in males, and 
about the umbilicus in both sexes. Pemphigus of the 
hands and feet is exceedingly rare in adults, and pom- 
pholyx has never been reported in infants. Moreover, 
pemphigus lacks the vesicular lesions of the sides of the 
fingers. Erythema bullosum is always on the back of 
the hands and wrists, and is not itchy, though it may 
burn. 

Treatment. — A simple astringent ointment, as of oxide 
of zinc, or diachylon; or an ointment of the oleate of zinc 
or lead; or an alkaline lotion, will allay the irritation 
and hasten the disappearance of the disease. Lassar's 
paste with 10 to 20 grains (0.66-1.33) of salicylic acid to 
the ounce (32) is a good application. It hastens the 
exfoliation of the old skin. When that has taken place 
it may be continued, without the salicylic acid, to pro- 
mote healing. General hygiene should be enforced; and 
tonics of iron, arsenic, or whatever seems indicated by 
the condition of the patient, given. 

Porrigo Contagiosa. — See Impetigo contagiosa. 

Porokeratosis. — Synonyms: Hyperkeratosis atrophica 
seu excentrica, Keratodermia eccentrica. 

Under this name Mibelli, 1 and later Respighi, 2 have 
described a disease of the skin that occurs in the form of 
raised or sunken yellowish-gray to brown patches of vari- 
ous sizes and irregular shape, with a continuous thin, 

1 Monatshefte f. prakt. Dermat., 1893, xvii, 417, also Annal. derm, 
et syph., 1905, vi, 503. 

2 Monatshefte f. prakt. Dermat., 1894, xviii, 70. 



532 



DISEASES OF THE SKIN 



horny, linearform tortuous ridge about them. The patch 
may begin as a very small, horny, dry, hard and acu- 
minate elevation which seems to well up from the orifice 
of a cutaneous gland. Around this the collarette forms. 
The patches may be small or one or more inches in diam- 
eter. The skin inside of the border may be normal, 

Fig. 78 




Porokeratosis. (Respighi.) 



rugous, smooth, scaly, or atrophic; while around the 
patches it may be normal, hyperemic, or pigmented. The 
amount of atrophy varies being most on the face and 
over bony prominences. The disease occurs on the dorsal 
and palmar surface of the hands and feet, the extensor 
surface of the forearm and leg, and exceptionally on their 



POSTMORTEM WARTS 533 

flexor surface. On the palms and soles and sides of fingers 
it takes the form of corns. It may also occur on the 
face, neck, and scalp, and the mucous membrane of the 
mouth. In the mouth the lesions vary in size from small 
pinhead to large lentil. They are sharply limited, with a 
linear, white, opaque border enclosing an opaline area 
that may be raised or flattened, convex or concave, or 
atrophic. There are no subjective symptoms. Some of 
the lesions may disappear spontaneously, and neighboring 
lesions may melt into each other. Generally the disease 
spreads slowly so as to occupy large areas. 

Respighi describes five distinct forms: (1) Miliary 
and submiliary papules; (2) Hemp-seed- to lentil-sized 
papules; (3) Guttate to nummular papules; (4) Ring and 
circinate disks, which is the most common form. Their 
edges are raised, regular, toothed, or zig-zag, and may be 
composed of papules arranged in chains. The disks may 
be round, oval or elliptic; (5) Ball-shaped lesions 3 to 
4 mm. high. All forms begin as papules. The disease 
is bilateral and tends to symmetry. The nails may be 
affected, becoming cloudy, striped longitudinally, rough, 
thickened, raised from their bed, brittle, and they may 
be shed. There are no subjective symptoms. The skin 
may be abnormally dry. 

The disease usually begins in early life, but may begin 
at any age. It is hereditary in some families. Most of 
the cases are in males. Many members of the same 
family may be affected. It is a very rare disease without 
known cause. It consists in a hyperkeratosis of the 
sweat-gland orifices and destruction of the glands. The 
sebaceous glands and hair follicles may be involved in 
the process. It is thought by Mibelli to be a species of 
papilloma lineare. It is an eminently chronic affection. 

The treatment consists in destruction by electrolysis 
or in excision. 

Port-wine Mark. — See Nevus. 

Postmortem Warts. — See Tuberculosis verrucosa cutis. 



534 DISEASES OF THE SKIN 

Prairie Itch. — This disease has been found to be in 
most cases a combination of pruritus hiemalis and 
scabies. It is not a disease sui generis. 

Prickly Heat. — See Miliaria. 

Prurigo. — Synonyms: Strophulus prurigineux; Scrofu- 
lide boutonneuse benigne; (Ger.) Juckblattern. 

A chronic disease of the skin characterized by begin- 
ning in infancy as an urticaria, and changing into a 
recurring eruption of pale, hard, exceedingly itchy, dis- 
crete papules, located especially upon the extensor 
surfaces of the extremities. It increases in severity from 
above downward, and is accompanied by enlargement 
of the inguinal glands. 

There are two types of this disease, namely, prurigo 
mitis and prurigo ferox. These blend into each other. 
While the malady is more commonly reported from 
Vienna than elsewhere, it occurs in many countries. It 
is rare in this country, and most of the cases met with 
are of the mild type. 

Symptoms. — The disease begins in infancy, quite com- 
monly toward the end of the first year, as an outbreak 
of urticarial wheals of various sizes and shapes. It may 
begin in childhood. The urticarial eruption persists, 
but after a time a preponderance of small wheals will be 
remarked, and a preference for the trunk and the extensor 
surfaces of the limbs. During the second or third year the 
urticarial element is lost and the characteristic papular 
eruption gradually preponderates, and at last takes its 
place. The papules are pinhead to hemp-seed in size, 
flat, firm, of the color of the skin, or of a bright-red, 
rosy, or yellowish-white color, and in many cases so 
little raised as to be felt rather than seen. When the 
skin is irritated the papules may assume the character 
of small wheals. The efflorescences are located principally 
upon the extensor surfaces of the limbs, and more sparsely 
on the trunk, while the scalp, the flexures of the large 
joints, the palms, soles, and genitals are free. The flexure 



PRURIGO 535 

surfaces of the extremities may be affected. The papules 
are not grouped. 

Pruritus is intense, so that excoriations and torn pap- 
ules are present over all the affected parts. The patients 
have a pale, weary expression of countenance, and evi- 
dently are in poor condition. The skin is often dry and 
it may be scaly. 

When the lesions are but few in number and scattered 
about upon the extremities we have prurigo mitis. When 
a great number of papules are present, and the disease is 
widespread, we have prurigo ferox. Now we have the 
typical form of the disease such as is shown in the Vienna 
skin clinics. We note that the skin feels rough; that it 
is strewed over with a great number of small papules which 
have the color of the skin or are pale red; defaced with 
scratch-marks; eczematous in places; darkly pigmented, 
it may be brown, from the constant irritation of scratch- 
ing, and that the color of the general integument is in 
strong contrast with the pale color of the face; that the 
skin is thickened in some places, while the flexures of the 
joints are free from change and as soft as normal; that 
these changes in the skin are progressively worse from 
above downward, so that the legs from the knees down 
are most markedly involved ; and that the inguinal glands 
are enlarged so as to form buboes. Ecthymatous lesions 
may arise. The intensity of the itching may be so great 
as to prevent sleep, and even in some cases to drive the 
patient insane. 

The duration of the disease is indefinite; it may last a 
lifetime, but often tends to disappear with advancing 
years. The type of the disease remains the same through- 
out — that is, prurigo mitis does not change to prurigo 
ferox. 

Etiology. — Prurigo affects both sexes, though it is 
more prevalent in the male sex. It is far more common 
among the poor, especially Europeans, and those who 
are uncleanly. It is not very common in this country, 
especially in the ferox type. It is not uncommon to find 



536 DISEASES OF THE SKIN 

several members of the same family with the disease. A 
phthisical family history has been affirmed to be an 
etiological factor by some authorities. Some cases are 
better in winter and some in summer. It is a disease 
of infancy continuing through life. It seems to be 
related to urticaria. A neurosis probably is the under- 
lying cause of the disease. 

Pathology. — The prurigo nodule is caused by an 
interstitial edema of the rete, with the eventual formation 
of vesicles. The papilla? are likewise edematous, and 
show perivascular infiltration. The early lesions much 
resemble urticarial papules. 

Diagnosis. — The diagnosis is made by the occurrence 
of pale papules upon the extensor aspects of the limbs; 
by the increasing severity of the symptoms from above 
downward; by the enlargement of the inguinal glands, 
by the peculiar look and complexion of the patient, and 
by the continuance of the disease from early infancy. It 
is differentiated from eczema by the sparing of the flexures 
of the joints; by the presence of the characteristic pap- 
ules, and by its greater obstinancy to treatment. From 
papular urticaria it can be distinguished only by its 
general course. In fact, a doubtful case must be carefully 
studied over a considerable length of time before a posi- 
tive diagnosis can be made. Scabies and pediculosis can 
be readily separated by the occurrence of the lesions on the 
palms, between the fingers, and on the genitals in the one; 
and the parallel scratch marks over the shoulders in the 
other. Ichthyosis spares the flexures as does prurigo, 
but it is marked by polygonal scales, not papules; and is 
free from the great number of excoriations found in 
prurigo; it is, moreover, a disease that affects the whole 
body-surface more generally. 

Treatment. — The disease is exceedingly obstinate to 
treatment. The patient must be put in as good physical 
condition as possible by means of hygiene, cod-liver oil, 
iron, and a good diet. Tincture of cannabis indica is 
commended by Crocker for relief of the itching, in doses 



PRURIGO 537 

of 5 minims (0.308) increased to 30 minims (1.84) to a ten- 
year-old child, given three times a day directly after 
meals, and intermitted for two weeks after every six weeks. 
These seem to me to be large doses. Simon 1 and others 
recommended pilocarpin hypodermically, 15 minims (1 ) of 
a 2 per cent, solution once a day, for adults, or a corre- 
sponding quantity of jaborandi by the mouth. After the 
dose the patient is to be put in bed and covered with 
woollen blankets, where he is allowed to sweat for two 
or three hours. Carbolic acid, 5 to 10 (0.33-0.66) grains a 
day in pill, and the bromide of potassium have their 
advocates. Antipyrin and phenacetin exert a controlling 
influence over pruritus, and they are among the most 
valuable internal remedies in prurigo. The latter, though 
not so active as the former, should be tried first in full 
doses, as it is much safer. Thyroid extract has been 
recommended. 

External treatment is very important. Naphtol is 
most highly commended, a 2 to 5 per cent, solution, 
according to age, being rubbed in every night, and a 
bath of naphthol-sulphur soap being taken every second 
night. In older children and adults the soap treatment of 
Hebra, as described in the section on Eczema, is useful. 
Sulphur ointment used as in scabies after a daily bath; 
tar used as in psoriasis; a 5 or 10 per cent, lotion of 
carbolic or salicylic acid, or the same combined with 
vaselin; a 5 per cent, boric acid ointment, all have their 
advocates and all may be tried in obstinate cases. Baths 
followed by inunctions of cod-liver oil, simple oil, tar oil, 
or lard, are often useful; as well as baths of alum, soda, 
and corrosive sublimate. Jacquet and Tenneson report 
great amelioration from wrapping the affected parts in 
some protective dressing, such as rubber sheeting or 
absorbent cotton. The spinal douche might do good in 
some cases. Treatment should be continued for weeks 
or months after apparent cure of the disease. 

1 Berlin, klin. Wochenschr., 1879, xvi, 721. 



538 DISEASES OF THE SKIN 

The prognosis as to cure is bad, excepting in recent 
and not severe cases. These may be cured. As a rule, 
all we can do is to mitigate the patient's discomfort. 
Relapses are the rule. A few young patients become well 
as they reach full maturity. 

Pruritus Cutaneous. — Symptoms. — By pruritus cutaneus 
we mean a functional neurosis of the skin whose only 
essential symptom is itching. This induces scratching, 
and scratch-marks are always to be found as a secondary 
symptom. These usually are in the form of scratched 
papules. If the itching is great and continuous, we will 
have other secondary effects, such as thickening and 
pigmentation of the skin, and eczema of various degrees. 

The itching varies greatly in degree, from simply an 
occasional slight attack to such an intensity as to render 
the patient's life unendurable and tempt to suicide. The 
pruritus is commonly paroxysmal, but in some cases the 
pauses between the paroxysms are so short that the itch- 
ing is practically continuous. It is almost always worse 
at night, and robs the sufferer of sleep. Changes of 
temperature aggravate the itching, as a rule. Very com- 
monly warmth makes matters worse, and the sufferer will 
begin to scratch and keep on scratching while in the 
neighborhood of a fire or in bed warmly covered. He 
cannot resist the impulse to scratch, and so in bad cases 
he shuns society and becomes morbid. 

Under the general title of pruritus are often placed 
various paresthesias, such as formication, tingling, and 
burning. 

The pruritus may be general or local. Thus we have 
pruritus universalis, a term that can seldom be applied 
with strict accuracy, as pruritus is rarely universal. 
In these cases the itching is now in one place and 
now in another. Bulkley, 1 by a series of observa- 
tions on himself, strove to establish some law of reflex 
excitation, in which he was so far successful as to find 

1 Jour. Cutan. and Gen.-Urin. Dis., 1887, v, 459. 



PRURITUS CUTANEOUS 539 

that if he scratched one spot that itched, he relieved the 
sensation there, only to have it break out elsewhere. 
This general pruritus is most often encountered in pruri- 
tus senilis, or the itching of the skin of old people, and in 
pruritus hiemalis and pruritus estivalis, which are induced 
respectively by the cold of winter or the heat of summer. 
These very often manifest themselves on the thighs and 
legs only. Bath pruritus is that form of itching which 
comes on after taking a bath, and lasts a variable time. 
Stelwagon has found that if the clothes are put on at 
once, the itching lasts for a shorter time than if the 
patient goes to bed. 

Of local pruritus we have many instances. Thus we 
have pruritus ani, which afflicts both sexes, though more 
often men than women, and in which the itching extends 
to the mucous membrane of the anus. The parts are 
often sodden looking and emit a disagreeable odor. This 
same extension is also seen in pruritus vufoce. This 
localized itching, with the corresponding pruritus scroti 
in men, often occurs in connection with pruritus ani. 
In all these three the parts almost always become thick- 
ened and eczematous from the constant rubbing and 
scratching to which they are subjected, and nympho- 
mania is sometimes a consequence of the itching vulva. 
The scalp, face, especially about the nose and mouth; 
the palms and soles, and between the fingers and toes, are 
frequent sites of itching. More rarely local areas any- 
where w T ill be affected with recurring attacks of itching. 

Etiology. — That the pruritus is due to a functional 
disturbance of the sensory nerves there is no doubt. Ac- 
cording to Bronson 1 it is due to a disturbance of the sense 
of contact. Those with naturally dry skin are more apt 
to suffer than those whose skin is moist. For success 
in treatment and accuracy in prognosis it is necessary for 
us to endeavor to determine the cause of such disturb- 
ance. The contact of wool irritates some skins. Hepatic 

1 Med. News, April 18, 1903. 



540 DISEASES OF THE SKIN 

derangements cause a certain proportion of cases. The 
intense itching of the skin in jaundice is evidence of this. 
Digestive disorders and constipation; excretory dis- 
orders, as of the kidneys and skin; albuminuria; lithemia; 
and diabetes, all have influence in causing pruritus. 
Depressed mental states, and the disorders of the nervous 
system induced by the abuse of tobacco, tea, alcohol, 
opium, and the like, produce pruritus. In tabes, pruritus 
often alternates with gastric crises. Pruritus is not 
infrequently met with during the menopause. Reflex 
influences from the sexual sphere and the power of 
imagination are responsible for some cases. In illus- 
tration of the latter, everyone knows how many people 
will begin to scratch when the subject of lice is mentioned; 
and how that long after the acarus is killed in scabies 
the patient will continue to complain of itching, and 
will not be assured that he is cured of his disease. 

In pruritus senilis the skin will be found to be atro- 
phied and the fatty tissue underlying it absorbed, in not 
a few cases. Pruritus ani is often due to hemorrhoids 
or fissures of the mucous membrane; or to ascarides; or 
to the excessive use of tobacco, as well as to the causes 
enumerated above. Stricture of the urethra has been 
found to be the cause of both it and pruritus scroti. 
Pruritus vulvae is very often due to leucorrhea, preg- 
nancy or tumors of the uterus or ovaries, or occurs 
during the menopause. In this form diabetes is quite 
commonly the cause. Pruritus hiemalis begins at any 
time from October to January, and continues until the 
spring is well advanced. The effect of cold upon the 
skin seems to check the secretory functions. 

Bulkley has found pruritus to be more common in 
men than women, fifty of his eighty cases being men. 
In some families an itching skin seems to be hereditary. 

Diagnosis. — If we bear in mind that pruritus has no 
lesion of its own; and if, whenever a patient complains 
of itching of the skin, we institute a search for the pedic- 
ulus, or the itch-mite, or their lesions; or the wheal, or 



PRURITUS CUTANEOUS 541 

at least a history of it; and find none, then Ave have by 
elimination gone far toward establishing a diagnosis of 
pruritus. Sometimes it is difficult to determine whether 
an eczema is secondary to the scratching for the relief of 
itching, or the itching is a part of the eczema. Only an 
attempt at curing the eczema and long observation of the 
case will enable us to make a true diagnosis. Many errors 
in diagnosis will be avoided by close study, as true pruri- 
tus is not so common as other itching diseases. 

Treatment. — To find and remove the cause is the first 
essential in treating a case. How difficult this task may 
be will be seen by a study of its etiology. Nevertheless, 
the patient must be considered, and every organ interro- 
gated, and every deranged function regulated as far as 
possible. Tea, coffee, alcohol, and tobacco should be 
interdicted; a dietary carefully laid down; and the rules 
of hygiene, such as those relating to exercise, bathing, 
and clothing, enforced. To relieve the itching as such 
we may give the tincture of cannabis indica, 10 minims 
(0.616) three times a day, in water after meals and gradu- 
ally increase the dose up to 20 (1.23) or 30 minims (1.84); 
or the tincture of gelsemium in 10-minim (0.616) doses 
every half -hour till 1 dram (3.7) is taken or toxic effects 
produced; hypodermic injections of pilocarpin y ¥ to -§- of a 
grain; quinin, 10 (0.66) to 15 grains (1) at bedtime; carbolic 
acid, 1 to 2 minims three times a day and increased; wine 
of antimony, 5 to 7 drops after meals; salicylate of soda, 
15 grains (1), or antipyrin or phenacetin in full doses. 
Besnier recommends valerian, or valerianate of ammo- 
nium. But the relief so obtained is transitory, and we 
should not rest content until we have found out, and 
where possible removed, the internal underlying cause. 
Opium should never be given, as it causes pruritus. 

Linser 1 had marked success from using serum injections, 
giving 10 to 20 c.c. daily for five successive days. He 
directs that 50 c.c. of blood be drawn in a sterile centrif- 

1 Dermat. Woch., 1912, liv, 365. 



542 DISEASES OF THE SKIN 

ugal glass. This is defibr mated by shaking for five 
minutes with glass pearls. It is then put in the electric 
centrifugal machine. The serum is used after allowing 
it to stand for half an hour. 

The external treatment is of great service in alleviating 
the itching, even if it does not cure the disease. For this 
purpose general baths with soda (§ viij to x to 30 gallons), 
or nitric or hydrochloric acid (gj to 30 gallons), may be 
used. After the bath the body is to be dried by wrapping 
in a warmed sheet and patting the skin dry; then the 
skin should be smeared with vaselin and powdered with 
corn-starch from a flour-dredger. For local pruritus we 
may use lotions, of which one of the most efficient is: 

1$ — Acid, carbol., 5j-ij 4-8 1 

Liq. potassae, 3j 4 

01. lini, ad 5j 32 | M. 

Sig. — Shake before using (Bronson) . 

The patient should be cautioned to tap the itching point 
gently with this, and not rub it in. So used, it will 
cause no damage and may stop the itching for hours. 
Carbolic acid may be used as a spray in the strength of J an 
ounce (16) to the pint (500) of water with 1 ounce (32) 
of glycerin. To this 5 to 20 minims of oil of peppermint 
may be added (Hardaway). Stelwagon recommends for 



general use: 






1$ — Ac. Carbolici, 
Glycerini, 
Alcohol, 

Aquae, 


3j-iij 4-12 

5ij 8 

Sj 32 

aa, ad Oj 500 


M. 


Alkaline lotions, as 


bicarbonate of soda, 5j (4) to the 


cupful of water; or 


acid lotions, such as vinegar dabbed 


on the itching spot, 


will often relieve. Liquor carbonis 


deter gens 5j to §iv 


(4 to 120) or 


fy— Thymol, 

Liq. pqtassse, 
Glycerin, 

Aquae, 


3ij 8 
3J 4 
3iij 12 
Sviij 250 


M. 



Liquor picis alkalinus, 3j to 5iv (4 to 120); or yerchloride 
of mercury, gr. J to 3 to gj of water, or resorcin, 3 to 10 



PRURITUS CUTANEOUS 543 

grains (0.2 to 0.65) to the ounce (32). All these are well 
attested as useful. Peroxide of hydrogen is highly com- 
mended by Bronson. It may be used as a toilet wash 
two or three times a day. 

For pruritus ani, scroti, et vulvae sitting over a basin 
or pail of very hot water and sopping it up on the parts 
followed by patting the skin dry and using a starch 
powder, will often give the patient a quiet night. Con- 
stipation, if present, must be relieved. If an eczema is 
present, that must first be cured. Cocain lotions, as one 
of 20 per cent, of cocain and 5 per cent, of glycerin; or 
menthol 3 to 10 per cent, in oil of sweet almonds, or of 
glycerin and water; and carbolic acid lotions are also 
useful, as well as the ointment of the ammoniate or 
nitrate of mercury. Schafer 1 says that bromotan, 10 per 
cent, in equal parts of lanolin and vaselin applied on a 
bandage two or three times a day cures quickly. Cocain 
had best be left alone, as there is always danger of form- 
ing the cocain-habit from the use of this seductive drug. 
Bulkley's antipruritic powder, of 1 dram (4) each of 
camphor and chloral rubbed together till liquefied, and 
added to 1 ounce (32) of starch powder, will sometimes 
prove very effective. The parts may be painted with 
nitrate of silver, gr. 15 (1) in spts. setheris nitrosi § j, (32) 
or with 15 per cent, solution of caustic potash. A saturated 
solution of boric acid is also good. When the parts are 
excoriated neither menthol, peppermint, nor the chloral- 
camphor powder can be used. Guaiacol 5 or 10 per cent, 
with starch powder, is one of the newer remedies. Sup- 
positories containing belladonna, cocain, or creosote may 
give relief in these cases. Of course, hemorrhoids, fissures, 
or other rectal diseases must be cured if found. The 
high frequency current, the x-rays or the Kromayer lamp 
may be used with great benefit. W. M. Banks 2 recom- 
mends in pruritus ani the use of the large bulbous-headed 
point of the Paquelin cautery, so as to frizzle the skin 

1 Frauenartz, 1906, xxi, 2. 

2 British Med. Jour., 1900, i, 561. 



544 DISEASES OF THE SKIN 

for an inch and a half about the anal orifice. If there 
are rugous folds a smaller cautery should be used. 

In pruritus hiemalis it is sometimes necessary for the 
patient to wear linen underclothing next the skin; and 
over it the woollens usually worn. Other patients find 
more relief from wearing silk underclothing. Anti- 
pruritic lotions should be prescribed and a dusting powder 
so freely used that the meshes of the underclothing are 
filled with it. The treatment indicated above for pru- 
ritus is applicable here also. In some cases the only 
relief is found in removal to a warmer climate. In pru- 
ritus senilis great relief is often obtained by simply 
keeping the parts well greased with eucerin or cocoa 
butter. 

In some obstinate cases of general pruritus great ame- 
lioration may be obtained by the actual or Paquelin 
cautery applied lightly along the spine. The same means 
has sometimes been successful in localized pruritus, as of 
the vulva or scrotum, but now the parts themselves are 
touched with the cautery. Spinal douches are highly 
thought of by some French authorities. In these chronic 
cases it must be remembered that a cure can be effected 
with difficulty as long as the patient is exposed to the 
wear and tear of his life. Many nervous patients are well 
when travelling or living out-doors. 

Prognosis. — The prognosis is doubtful. Some cases 
are very obstinate, and some are incurable. Happily, 
thorough study of the case will be rewarded in most 
instances by a cure. 

Pseudo-erysipelas. — By this term is meant cellulitis or 
diffused phlegmon. 

Pseudoleukemia Cutis is a very rare disease. It is a 
form of Hodgkin's disease. A case is reported by Joseph 1 
as occurring in a man in previous good health. It com- 
menced as a number of small glandular swellings in the 
neck. Shortly after their appearance severe general 

1 Deutsche med. Wochenschr., 1889, p. 946. 



PSORIASIS 545 

pruritus began to aft'ect the patient. Then the inguinal 
and axillary glands became greatly enlarged, and a 
general eruption of hemp-seed-sized papules occurred. 
These were more easily felt than seen, and were of a 
pale-red color. The epidermis over them was unchanged. 
Wheals also appeared that changed into papules. The 
skin between the papules was dark-colored, thickened, 
and dry. The case ran a chronic course, marked by 
relapses. 

Psoriasis. — Synonyms: Lepra Grecorum ; Lepra alphos; 
Alphos; Psora; (Ger.) Schuppenflechte. 

A disease of the skin characterized by an eruption of 
round or ova l, bright-red patches covered with more o± 
less thick, sil very- white T adherent sca les; by occurring 
especially upon the extensor surf aces oftKe elbows, knees , 
and extremities, and upon the^ calp; by running a chroj iic 
course marked by remissions and relapses; and by being 
more or less pruritic. 

This is one of the more common skin diseases forming 
in this country about 3 per cent, of all cases. 

Symptoms. — Its features of variously sized, sharply 
defined red papules or patches covered with more or less 
abundant silvery-white scales that occur especially upon 
the extensor surfaces of the elbows and knees, are so 
pronounced that the disease once seen is readily recog- 
nized even by the tyro. 

The primary lesion of psoriasis is always a pinkish or 
bright-red, pinhead-sized papule covered with a dry 
sil very- white or grayish scale. It is rare to meet with a 
case in which these small lesions are seen alone, and when 
it is, it is called psoriasis punctata. Careful search of 
any but an inveterate case will be rewarded by finding 
these lesions somewhere on the body. They soon begin 
to enlarge by peripheral extension into larger patches, 
which have received various names, although preserving 
the same, essential characteristics. When they attain the 
diameter of about one-quarter of an inch, and bear a 
85 



546 



DISEASES OF THE SKIN 



rather thick scale, they look like drops of mortar, and the 
case is then spoken of as psoriasis guttata. When the 
lesions form coin-sized patches we speak of psoriasis 
nummularis. A single patch may grow to be two inches 
in diameter, or even larger, and preserve its circular 



Fig. 79 




Psoriasis. (From Prof. G. H. Fox's service in the Vanderbilt Clinic.) 

shape. But the large patches are usually formed by the 
coalescence of several smaller patches, and may attain 
to a size sufficient to cover the greater part of a limb or 
even the trunk. Its circular outline is now lost, and the 
patch has a more or less scalloped, indented border 
bearing so strong a resemblance to the maps drawn by 



PSORIASIS 



547 



children that Piffard suggested the term psoriasis geo- 
graphica for it; but the more usual name is psoriasis 
diffusa. After a patch has reached a certain size it may 
clear up in the centre and form a ring, and in this way 
we have psoriasis circinata. Several of these rings may 



Fig. 80. 




Psoriasis. (From Prof. G. H. Fox's service in the Vanderbilt Clinic.) 



meet at their circumference, when the points of contact 
will disappear and gyrate figures will be formed. When 
the eruption is so general as to involve the whole or 
greater part of the body, we speak of it as psoriasis 
universalis. Not infrequently these cases bear a striking 
resemblance to dermatitis exfoliativa. 



548 DISEASES OF THE SKIN 

Every case of psoriasis does not exhibit all these varie- 
ties, because the disease may stop at any period of its 
evolution. But in any case there is apt to be a number of 
variously sized lesions. Whatever the size of the patch 
may be, it will always be observed that the redness 
extends but little beyond the scales. The amount of the 
scaling will vary. Sometimes the scaling will be but 
slight; sometimes it will be so abundant that it will heap 
up into such crust-like masses as to suggest the adjective 
rupioide. The scales are constantly being shed, and as 
constantly renewed. They may be readily scraped off 
with the nail; and if this is carefully done, a delicate 
glistening membrane will be exposed, under which will 
appear dot-like red points. That is, we have removed 
the epidermis and exposed the mucous layer of the skin, 
the red points being the tops of the slings of bloodvessels 
of the papillae. This is thought by some to be character- 
istic of psoriasis, but with care it may be produced in 
other diseases. 

The color of the scales is silvery white or grayish. 
Darker scales are due either to the deposition of dust or 
the admixture of blood. The color of the patch will vary 
from a pinkish red to a dark red, the darker color being 
seen upon the legs, where the color of all lesions is darker 
on account of the partial stasis in the return flow of blood. 
The disease is always a dry one, there being absolutely 
no discharge feature in its course. The patches are 
sharply defined, but so little raised that they can be nearly 
all scratched away. 

While psoriasis may occur anywhere on the body, and, 
as we have seen, may become universal, its most fre- 
quent locations are the extensor surfaces of the limbs, 
elbows, and knees, or rather the face of the tibia just 
below the knee, and the scalp. It may occur upon the 
first two locations alone. When it occurs upon the 
scalp careful examination will generally show some 
lesion elsewhere on the body, and we will usually find 
a little patch in front of the ears, and very often there 



PSORIASIS 549 

will be a red scaly line on the forehead just in front of 
the hair-line, a feature that is as striking and as char- 
acteristic of psoriasis as the corona veneris is of syphilis. 
The hair does not fall, as a rule. In some cases, how- 
ever, we may have transient or permanent alopecia. 
The whole scalp may be covered with a continuous 
patch, or distinct scaly patches may form as on the 
body. In any event the border of the patch will be 
sharply defined. It is very rare to find psoriasis on the 
mucous membrane of the mouth. M. Oppenheim 1 has 
seen one case developing there in connection with 
marked psoriasis of the rest of the body. It appeared 
in the form of bluish-white, sharply defined, oval, raised 
patches of various sizes. 

The palms and soles are very rarely the seat of the dis- 
ease, and then only as part of general psoriasis. It is 
true that a few cases have been reported in which it has 
been said to have been located upon one hand alone, and 
this by competent observers; but all the probabilities are 
in favor of such cases having been either syphilis, which 
is most likely, or squamous eczema. The disease is 
bilateral, and sometimes may show a decided tendency 
to symmetry. 

In old, inveterate cases there may be considerable thick- 
ening of the skin, a feature that is usually wanting, and 
fissures may form about the joints that may be painful 
and bleed. This may also occur on the scrotum, or on the 
trunk where the skin is in folds. 

The nails are affected in some cases, becoming opaque, 
lusterless, furrowed transversely, discolored, and some- 
times cracked; while they are raised from their beds by 
the accumulation of scales underneath them. All the nails 
are rarely diseased at the same time; usually it is but one 
or two nails on each hand or foot. Sometimes the disease 
is limited to a strip along the side of one nail. 

There is no constitutional disturbance in this disease, 

1 Monatshefte f. prakt. Dermat., 1903, xxxvii, 489. 



550 



DISEASES OF THE SKIN 



the patients usually being in as good health as the majority 
of people. Sometimes they have pains in the joints 



Fig. 81 




Fig. 82 




Psoriasis of the hands. (By the courtesy of Dr. S. I. Rainforth.) 



that are regarded as rheumatic by some, and as neurotic 
by others. Itching is very often an annoying symptom. 
Sometimes it is entirely wanting. 



PSORIASIS 



551 



The course of the disease is variable. Although it is 
always chronic, it presents at times acute symptoms. 
Relapses are the rule, to which there are few exceptions. 
In some cases the skin will be entirely free from all trace 
of the disease for months or years. In most cases this 
freedom is only partial; even though the patient thinks he 
is clean, some little spot will be discoverable. The dura- 
tion of each patch is also variable. It may disappear in a 
few weeks or remain for months. Most cases are better 

Fig. 83 



Psoriasis of the sole. (By the courtesy of Dr. S. Dana Hubbard.) 

in summer, to become worse in winter. When the patches 
disappear, they do so completely, though a slight amount of 
scaling may be present for a short time. Lederman 1 has 
seen leucoderma follow the disappearance of the lesions. 
In a few very rare cases a chronic psoriatic patch has 
become papillomatous and then epitheliomatous. 

Etiology. — Various theories have been advanced in the 
etiology of psoriasis, and some facts have been estab- 
lished by our study. We know that the disease is heredi- 

1 Archiv f. Dermat. u. syph., 1907, lxxxiv, 359. 



552 DISEASES OF THE SKIN 

tary in a number of cases. Greenough 1 found the pro- 
portion as high as one-third. It may occur at any age. 
Kaposi has reported a case at eight months of age, and 
Riehl 2 one at thirty-eight days. Whitfield has had one 
case three weeks old. It usually is a disease of early 
adult life, making its first appearance before the thirtieth 
year. A primary attack is rare after the fiftieth year. 
It affects both sexes and all conditions of life. These 
things we know. 

While the majority of patients seem to be in the best 
of health, some are rheumatic or gouty. In some cases 
there will be an unusual amount of indican in the urine. 
A lowered condition of the general health seems, in some 
cases, to favor an outbreak either of a primary attack or of 
a relapse. Thus, it is no uncommon thing to see the disease 
in women growing worse during pregnancy or lactation. 
Malassimilation or digestive disorders also seem to aggra- 
vate or provoke the disease, Hardaway even affirming that 
he has known the inordinate eating of oatmeal to cause 
the disease, while Gowers 8 reports cases produced by the 
ingestion of borax as a medicine. Hyde is inclined to 
believe that as the disease occurs most upon covered parts, 
deprivation of the skin from contact with the sun's rays, 
may be one cause of it. Polotebnoff 4 has written an 
elaborate thesis to show that the disease is a vasomotor 
neurosis, affirming that in a majority of cases there will 
be found evidences of either trophic or vasomotor disturb- 
ances, or a history of more or less profound nervous 
troubles either in the patient or his family. A number 
of cases following fright or nerve-shock have been re- 
ported. In the Vierteljahr. f. Derm. u. Syph., for 1878, 
Lang brought out his parasitic theory, and in No. 208 of 
Volkmann's Sammlung klin. Vortrdge the thesis is further 
elaborated, the fungus being represented by illustrations. 

1 Boston Med. and Surg. Jour., 1885, cxiii, 163. 

2 Monatshefte f. prakt. Dermat., 1895, xxi, 283. 

3 Lancet, October 24, 1884. 

4 Monatshefte f. prakt. Dermat., 1891, Erganzungsheft, No. 1. 



PSORIASIS 553 

lie has found some support from other observers, but the 
parasite he described has not been accepted as the cause of 
the disease. Destot produced the disease in a man by 
inserting a piece of psoriatic skin into a freshly scarified 
place. This was followed by an eruption of psoriasis 
which ran the usual course with four relapses in two 
years. 1 Crocker accepts the parasitic theory, and accounts 
for the wide distribution of the disease by assuming that 
the parasite gains entrance into the blood from the point 
of inoculation, and through the circulation affects the 
general skin. 

It is a well-known fact that an injury to the skin of a 
psoriatic, such as a pin-scratch, will determine the loca- 
tion of a patch of psoriasis. 

Pathology. — Pathologists by no means agree in their 
teachings as to the histology of psoriasis. By some it is 
regarded as inflammatory, while others believe it to be a 
keratolysis, or an anomaly of cornification in which an 
imperfect corneous layer is formed. Some teach that the 
process begins in the rete, and the changes in the corium 
are secondary; while others hold the reverse view. Lang 
names his parasite epidermidopliyton, and describes it as 
composed of mycelia and spores, either disseminated or in 
groups, which are so delicate as to be seen only with very 
high powers. 

Histologically there appears to be a hyperplasis of the 
rete, except directly over the papillae, which latter are 
enlarged and more vascular than normal. The epi- 
dermis seems composed of only two layers, the thickened 
rete, and the parakeratotic corneous layer, the lamellated 
loosely coherent strata of which still retain their nuclei. 
There are serous cellular infiltrations in the upper corium, 
especially about the hair follicles, sebaceous glands, and 
enlarged bloodvessels. 

Diagnosis. — A typical case of psoriasis presenting 
round or oval, variously sized, pinkish-red, dry patches 

1 Hallopeau: Ann. de derm, et syph., 1901, ii, 337. 



554 DISEASES OF THE SKIN 

covered with thick silvery-white scales, scattered more or 
less generally over the body, but showing a marked 
preference for the extensor surfaces of the extremities, 
and especially of the elbows and knees, is readily recog- 
nized. In some less typical cases it needs to be differ- 
entiated from syphilis, eczema, dermatitis exfoliativa, 
lichen ruber, and lichen planus, seborrheal dermatitis, 
and possibly from lupus erythematosus. From the 
papulosquamous syphilide of the secondary stage of the 
disease it differs by showing preference for the extensor 
surfaces of the limbs and the posterior surface of the 
trunk, though there are many exceptions to this rule. 
The syphilide is not so scaly; its red is darker, more 
raw-ham colored; the lesions are more infiltrated, giving 
a more shotty feeling to the ringer; they do not itch; 
they run a more acute course, and are of more uniform 
size, never exhibiting the patchy character of psoriasis. 
It is usually easy to establish the presence of other mani- 
festations of syphilis, such as sore throat, pains in the 
bones, fall of the hair, and perhaps the remains of the 
initial lesion. The later scaly syphilide is never general; 
is unsymmetrical, usually consisting of one or two groups 
of lesions that show no tendency to affect the elbows and 
knees. The lesions are more raised and prone to leave 
scars. There will also be the history of past syphilides 
to guide us, and an absence of those relapses so common 
and characteristic of psoriasis. The Wasserman test if 
positive will decide in favor of syphilis. 

Eczema squamosum is far more pruritic than psoriasis 
usually is; the patch is more infiltrated; the scaling is 
less, the scales being thinner; exudation can be readily 
induced; and a history of moisture at some time will be 
found. The patch of eczema is generally less sharply 
defined, and is more apt to shade off into the surrounding 
skin. If the scales of a psoriatic patch are removed, a 
delicate membrane is left showing red dots — the tops of 
the bloodvessel slings in the papillae; if the same thing 
is done in eczema a discharging surface will be left. 



PSORIASIS 555 

It is quite impossible to differentiate a true case of der- 
matitis exfoliativa at first sight from one of general pso- 
riasis. If it does arise from psoriasis, there will be a 
history of its gradual spread from typical lesions, quite 
different from what obtains in true dermatitis exfoliativa, 
which is more rapid in its evolution. Psoriasis is rarely 
so absolutely universal as is dermatitis exfoliativa. 
Watching the case for a time will establish the diagnosis. 
If psoriasis is the malady, it will declare itself after a 
time by the diffused redness clearing up and typical 
psoriatic patches showing themselves. 

Lichen ruber presents small, pointed papules upon the 
trunk at first, and not the large scaling papules upon the 
extensor surfaces of the limbs as in psoriasis. When the 
disease becomes general we will have the history of those 
lesions, and the skin will be more thickened and rugose. 

Lichen planus occurs by preference on the flexor rather 
then the extensor aspects of the limbs, and in the form 
of flat, shining, angular, smooth papules, rather than of 
round, freely scaly ones. The color of its patches is 
violaceous and not bright red. If it becomes universal, it 
does so evidently by the springing up of new small 
lesions between the old ones, and not by the peripheral 
growth and coalescence of those already existing. The 
thickening of the skin is also much greater than in 
psoriasis. 

In the diagnosis from seborrheal dermatitis Unna lays 
great stress upon four points: (1) Seborrheal dermatitis 
spreads from above downward, mostly in the middle line 
of the body, and its lesions are quite stationary in char- 
acter; while psoriasis begins on the elbows and knees, 
and more speedily affects the whole body. (2) There is 
always a history of a seborrheal affection of the scalp 
in seborrheal dermatitis. (3) The scales of seborrheal 
dermatitis are fatty and crumbling, and the patches are 
yellowish; in psoriasis the scales are white and friable, 
not greasy, and the patches are bright red. (4) The 
proneness of the patches of seborrheal dermatitis to form 



556 DISEASES OF THE SKIN 

bow-shaped figures, or rings more or less broken. Psori- 
asis may be circinate, but the margins of the figures 
are not so narrow and not follicular as they may be 
in seborrheal dermatitis. 

Treatment. — Though external treatment alone will 
often remove the evidences of psoriasis from the skin, 
producing a cure of the disease — if that may be said of 
a disease that is almost sure to relapse — we generally can 
procure more prompt results by a combination of internal 
and external remedies. The first inquiry in all cases 
should be made as to the general condition of the patient, 
and we should endeavor to establish in him as perfect a 
state of health as is possible. A restricted diet certainly 
does have a good deal of influence in causing an amelio- 
ration of the disease, and most authorities forbid the use 
of red meats. No hard-and-fast lines can be set in this 
respect. In the service of Prof. George Henry Fox, who 
is a strong advocate of dieting in skin diseases, we have 
seen some patients improve under a strictly vegetable diet, 
and others do equally well on a dietary composed largely 
of milk and animal food. A stout, evidently overfed, 
plethoric patient will be benefited by abstaining form all, 
or nearly all, meat. In this class of patients it is a good 
plan to insist upon a milk diet for a few days. An ane- 
mic, underfed patient will, on the other hand, improve 
under a more liberal dietary. Alcoholics, and especially 
malt liquors, should be interdicted in all cases, as well as 
rich gravies and highly spiced foods. 

Besides these general measures we have a number of 
drugs that have gained a more or less well-earned reputa- 
tion as remedies for psoriasis, though it must be con- 
fessed that they are more or less empirical remedies. 

Arsenic would be named, without doubt, by most gen- 
eral practitioners as the remedy for psoriasis. It does do 
good in this disease, but at the same time it is not to be 
considered as a true specific. In acute cases it aggravates 
the disease and should never be given. In chronic cases 
that have proved very stubborn it may be tried, and some- 



PSORIASIS 557 

times it will produce a speedy cure. When the disease 
begins to disappear, it will hasten its disappearance. The 
vast majority of cases will do quite as well without it. 
It may be given in the form of Fowler's solution with or 
without the wine of iron, and administered in water three 
times a day after meals. The initial dose for an adult 
should be about 3 drops, and the amount should be grad- 
ually increased until the limit of toleration is reached. 
Crocker thinks that the efficiency of this form of arsenic is 
enhanced by the addition of \ a dram (2) of the tincture 
of lupulus to each dose. The Asiatic pill is the favorite 
mode of using arsenic in Vienna. It is composed, accord- 
ing to Kaposi, of — 



— Pulv. ac. arsenosi, 


gr. xj 






75 


Pulv. piperis nigrae, 


3iss 




6 




Gummi acaciae, 


gr. xxij 




1 


50 


Pulv. althse. rad., 


gr. xxx 




2 




Aqua?, 


q. s., 


q- 


s. 


M 


Div. in pil. No. c . 











One pill is given after meals, and the dose is increased 
gradually every four of five days until 10 or 12 are taken 
each day, unless some constitutional disturbance is 
caused. The method of increase is by first giving 
1 pill after each meal; then 2 pills after breakfast, and 

1 after the other two meals; and then 2 after breakfast, 

2 after the midday meal, and 1 in the evening, and so on. 
Or, we may make use of the tablet triturates of arsenous 
acid with piperina, giving those containing -$-$ of a grain of 
the arsenic in the same manner as with Asiatic pills. Any 
other preparation of arsenic may be used. Hypodermic 
injections of arsenic or the cacodylate of sodium have 
been employed with success, but it would be hard to 
induce an American patient to endure this method. Stel- 
wagon reports occasional success from using in this way 
sterilized Fowler's solution with f grain of carbolic acid 
to 5 minims of Fowler's solution. He begins with 3 
minims of the mixture diluted with 4 or 5 parts of water, 
once a day. The administration of the drug must be 
persisted in for a long time, and it may prove curative 



558 DISEASES OF THE SKIN 

by itself. It is best not to continue its use for more than 
three or four months, as it is apt to produce permanent 
and general pigmentation of the skin and keratosis. 

Alkalies that act as diuretics are often very helpful, 
quite apart from any indication for their use on account 
of gout or rheumatism. A beginning psoriasis, or even a 
case of some duration, will be favorably influenced by the 
administration of the acetate or citrate of potassium in 
15-grain (1) doses before meals, well diluted, and followed 
by drinking J a glass of water. The undoubted efficacy of 
large doses of the iodide of potassium, as recommended 
by Haslund, 1 may depend, in part at least, upon its 
diuretic action. He gives the salt in increasing doses, 
so that as much as 600 grains have been administered 
to one patient during the day. When assistant phy- 
sician to the New York Skin and Cancer Hospital, in 
Dr. G. H. Fox's division, I tried Haslund's plan in 
several cases. They certainly were greatly benefited. 
The objections to this method are the expense of the drug 
and the danger of the sudden production of poisoning, 
shown by palpitation of the heart, severe headache, and 
faintness, necessitating either the keeping of the patient 
in a hospital or under the constant attendance of a 
physician. 

Turpentine oil is highly commended by Crocker as 
follows: It may be given in capsule, or, preferably, as an 
emulsion rubbed up with mucilage of acacia. The initial 
dose is 10 minims three times a day after meals. It may 
be increased by 5 or 10 minims at a dose until the patient, 
if tolerant of it, is taking 30 minims three times a day. 
Barley-water must be freely drunk during the day to 
prevent any bad effect on the kidneys, and the last dose 
of the turpentine should be taken not later than six or 
seven o'clock in the evening. Dyspepsia and irritability 
of the urinary organs contraindicate its use. The same 
authority advocates the use of salicylate of soda in 15- 

1 Vierteljahr, f. Derm. u. Syph., 1887, xiv, 677. 



PSORIASIS 559 

grain (1) doses three times a day after meals, or salicin in 
dosage of 15 grains (1) three times a day, increased to 20 
grains (1.33). Dilute lactic acid, 10 (0.66) to 30 (2) drops 
well diluted may be given before meals. The Bulgarian 
lactic acid cultures or tablets may be used, and seem to 
have some virtue. 

The wine of antimony in 5 to 10 minim (0.33 to 0.66) 
doses is recommended by Sir Malcolm Morris as efficacious 
in acute cases. Hyde speaks well of the protiodide of 
mercury, -J- grain three times a day. 

Chrysarobin by the mouth, { of a grain in sugar of 
milk three times a day, and increased to 1 or 2 grains 
at a dose, acts well in some cases, but is very apt to 
cause so much nausea and vomiting as to compel its 
discontinuance. 

Carbolic acid in drop doses t.i.d. after meals, gradually 
increased, certainly is helpful in some cases. It may be 
exhibited in glycerin and peppermint water and is well 
borne. It may be given up to 20 grains (1.33) a day. It 
cannot be given to those who have any renal disease. 

PolotebnofT, believing the disease to be a neurosis, 
advocates the use of bromide of potassium and of ergot. 

As most patients are worse in winter than they are 
in summer, when the skin is more moist from active 
perspiration, a residence in a mild climate might well 
be commended to a chronic psoriatic. 

External treatment. — Before making any application to 
the psoriatic skin the scales must be removed by bathing 
with soap and water, or by warm alkaline baths. Some- 
times bathing followed by inunctions of the skin with 
simple oil, or vaselin, combined with attention to diet, 
will produce a cure. These measures should be tried first 
in all beginning cases. In some cases there will be well- 
marked eczematous conditions. Then we must use 
remedies applicable to that disease. Generally we must 
resort to more stimulating remedies. The most useful 
and most promptly curative external remedy is chrysarobin 
(chrysophanic acid). The objections to it are its tendency 



500 DISEASES OF THE SKIN 

to produce an acute dermatitis and its permanent staining 
of everything with which it comes in contact. These 
unpleasant effects may be in part overcome by combining 
the drug with flexible collodion or traumaticin, but only 
in part. The dermatitis is always most marked upon 
those parts in which there is laxity of the skin, and if it 
is used on the face it is prone to produce great swelling 
about the eyes. Care must be taken not to get it in the 
eyes, as it causes violent conjunctivitis. These effects 
should make us very cautious about using it on the 
scalp, and prevent its use on the face. 

The most active form in which to use the drug is in an 
ointment, as of lard, lanolin, or vaselin. Gelanthum 
and plasment are excipients that have the merit of not 
being greasy, and of being readily and entirely removed 
by means of water. Flexible collodion and traumaticin 
(liquid gutta-percha) are good excipients. The drug may 
be rubbed up with water into a paste and applied to the 
spots and then covered with a piece of oxide of zinc 
plaster. This is a neat way of using it where there 
are but few patches. 

The strength of chrysarobin should not exceed 1 dram 
(4) to the ounce (32), as a rule; though in exceptional cases 
it may be used in greater strength. Its activity is increased 
by the addition of salicylic acid (3 per cent.), and then it 
is best to use it in a lower percentage, even 5 per cent, 
being active enough. An alkaline bath before using 
the chrysarobin increases its potency. If we use an 
ointment, it should be thoroughly rubbed in once a day 
after the scales are removed. If the vehicle is gelanthum, 
plasment, collodion, or gutta-percha solution, the spots 
should be painted over as often as the film left by the 
application falls. The patient should always be warned 
against getting the drug in the eyes. A favorite formula 
of Dr. George H. Fox is the following: 

1$ — Chrysarobin, 

Ol. cadini, aa 2 parts. 

Ac. carbolici, 1 part. 

Ac. oleic, 50 parts. M. 



PSORIASIS 561 

The combination recommended by Dreuw has shown 
itself in my hands the best way of using this drug. I 
use a modification of his formula as follows : 

1$ — Ac. salicylici, 3iiss 10 

Chrysarobin, 

Ol. rusci, aa 5v 20 

Adepis lanaB, 
Adepis anserini, aa 3vj gr. xv 25 M. 

The chrysarobin reaction is usually mild. 

If the chrysarobin produces too great a reaction, it 
must be stopped, and the skin treated with vaselin and 
starch powder, or an alkaline wash; or a smaller dosage 
may be tried, even as small as two or three grains to the 
ounce. The action of the drug upon the skin is peculiar. 
It stains the skin about the patches a mahogany red, 
while the patches become smooth and white. It discolors 
the nails and the hair, but after a time the staining 
disappears. Not so the staining of the clothing, which 
is permanent. It is said that it can be somewhat less- 
ened by soaking the clothes in plain water before using 
soap in washing. 

Before chrysarobin was discovered much reliance was 
placed on the ointment of the ammoniate of mercury. It 
is still a reliable remedy, but it cannot be used over 
the whole body in a general psoriasis' on account of the 
danger of absorption of mercury. It is the pleasantest 
and promptest application to the scalp and face, and 
can be used there while chrysarobin is used on the rest 
of the bodv. An ointment of 



i\- 



Hydrarg. amnion., 


gr. xx 




1 


Hydrarg. chlor. mitis, 


gr. xl 




2 


Petrolati, 


ad 3j 


ad 


32 



33 
66 

M. 



is sometimes better than that of the ammoniate by itself. 
Other mercurial ointments, such as that of the yellow 
oxide, and a dilute ointment of the nitrate, may be used. 
Lang has found the bichloride of mercury in collodion in 
1 to J per cent, strength a good application. It would 
probably be an unsafe one in a case of any extent. 
36 



562 DISEASES OF THE SKIN 

Tar is another old and reliable remedy, still much used 
in France. It may be employed in an ointment, or oil, 
or dissolved in alcohol. The oil of cade, oil of birch, or 
pure tar may be used in the strength of \ dram (2) to 4 
drams (16) to the ounce (32). In Paris the following is 
sometimes used: 

1$ — Glycerol, amyli, 

01. cadini, aa 500 parts. 

Sapo. viridis, 5 " M. 

This is to be rubbed in at night; the patient is to sleep 
in a flannel gown, and wash the ointment off in the 
morning. 

Kaposi recommended the following: 

1$ — 01. rusci, 50 parts. 

iEtheris sulphuris, 

Alcoholis, aa 75 " 

Filtra et adde 

01. lavandulae, 2 " M. 

Balzer 1 reports cures in a month or six weeks by giving 
20 to 30 baths containing 



\ — 01. cadini, 


3xiiss 




50 


Yolk of egg, 


No. i 


No 


1 


Ext. quillayse Ad., 


5iiss 




10 


Aquae, 


ad 5 viij 




250 



M. 

The patient is to remain in the bath for about one 
hour. If a slight erythema is caused the baths may be 
omitted on two days of the week. The body may be 
anointed with vaselin at night. 

Tar in any form is a dirty application, and is prone to 
produce inflammation of the skin, as well as toxic symp- 
toms. Anthrasol, which is a colorless tar, should be used 
on exposed parts. 

Pyrogallol (pyrogallic acid) is efficacious, but can be 
used only in cases in which the eruption is not extensive, 
on account of its poisonous action when absorbed. It 
may be used in the strength of about 10 per cent, in 

1 Bui. Soc. franc, do derm, et syph., 1912, 70. 



PSORIASIS 563 

ointment. It stains the skin, but causes less inflamma- 
tory reaction than chrysarobin does. 

Thymol was introduced by Crocker. It may be used as 
an ointment or lotion in the strength of 15 grains (1) to 
3 drams (12) to the ounce (32). As it is colorless and of 
pleasant odor it is suitable for use on the face. The same 
authority advocates the use of turpentine locally. He uses 
the oleum pini sylvestris with sufficient oil of lavender 
or essence of lemon to mask its odor. If used undiluted, 
the skin must be smeared with vaselin to prevent its 
cracking. It is better to use it diluted with olive oil, 
5j (4) of oil of turpentine to gvij (220) of olive oil, the 
proportion of the oil of turpentine being increased as the 
skin becomes accustomed to it. The addition of oil of 
cade or oleum rusci to the mixture increases its efficacy. 

Salicylic acid, 5 to 20 per cent, strength, will remove 
the scales, and in some cases will prove curative. It is 
often a good plan to add it in 3 to 5 per cent, strength to 
our other ointments. The soap treatment, as described 
under chronic eczema, is of great value in some chronic 
circumscribed cases. Sulphur ointment, oleate of copper 
"rufigallic" acid, 10 per cent, in ointment, and resorcin, 
have all done well in some cases. Anthrarobin, and 
aristol have not proved themselves as active as some of 
the older remedies. 

Gallacetophenone in 5 to 10 per cent, strength as an 
ointment or dissolved in collodion may be tried, but is not 
as good as chrysarobin. 

Some patients have found benefit from the use of 
natural mineral waters at spas. It is possible that much 
of the benefit so obtained is from the prolonged and 
regulated bathing. Wearing rubber clothing next the 
skin, or with a fine piece of muslin between the rubber 
and the skin to avoid the production of eczema by the 
rubber, will soften and remove the scales, and hasten the 
disappearance of the patches. 

The x-rays are useful to remove chronic obstinate patches. 
Caution must be used in their use. The lesions disappear 



564 DISEASES OF THE SKIN 

in from three to six weeks. The Kromayer lamp is 
useful especially in obstinate patches. Hyde and Mont- 
gomery recommend sun-baths daily or several times a 
week, and Stelwagon speaks well of exposure of the 
skin to the arc light. 

In psoriasis of the nails a 2 or 3 per cent, ointment of 
salicylic acid, pushed beneath the nail as far as possible, 
is a reliable remedy. The nails may be scraped thin and 
the finger ends wrapped up in the same ointment. 

Prognosis. — A cure of psoriasis may be promised 
with a fair degree of certainty so far as the removal of 
the eruption then out is concerned; but no promise can 
be made that the disease will not relapse. In this respect 
psoriasis resembles rheumatism and gout. While most 
relapses are readily removed in the course of a few weeks, 
in some cases one or more patches will be remarkably 
obstinate. 

Psorospermosis Follicuiaris Cutis. — See Keratosis follic- 
ularis. 

Pterygium is simply an overgrowth of the normal nail- 
fold at the proximal end of the nail, so that it covers to a 
greater or less extent the lunula. It may be cut off. 

Purpura. — Synonyms: Hemorrhea petechialis; (Ger.) 
Blutfleckenkrankheit. 

Symptoms. — By this term is meant a hemorrhage into 
the skin which is not caused by direct traumatism. It is 
always readily recognized by the red, purple, or blue- 
black color of its lesions, which cannot be made to dis- 
appear by pressure. The hemorrhage may take place 
into any part of the skin; into the subcutaneous tissues; 
or into any of the glandular apparatus of the skin. It 
occurs with suddenness, and produces variously sized 
lesions to which certain names have been applied. When 
they are small, from pin-point size to perhaps half an 
inch in diameter, they are called petechia. When occur- 
ring in the form of more or less long streaks they are 



PURPURA 565 

called vibices. Large bruise-like lesions with more or less 
swelling are ecchymoses. Blood tumors of all sizes are 
ecchymomas or hematomas. The color of all purpuric 
lesions depends upon their age. When first formed they 
are bright red, claret, or purple. Before disappearing 
they pass through various shades of color such as are 
seen after an ordinary bruise, becoming blue black, green- 
ish black, or brownish. These changes are due to the 
gradual absorption of the effused blood and the hematin 
deposited from the blood globules. There is no definite 
time for complete absorption to take place, but eventually 
no trace is left of the previous hemorrhage. 

If the extravasation of blood takes place into the hair 
follicles, we will have papules formed. If between the 
layers of the epidermis, hemorrhagic bullae may result. 
Hemorrhage into sweat glands will give rise to hemati- 
drosis. As complications of other dermatoses hemor- 
rhage may occur, as in urticaria, pemphigus, and eruptive 
fevers, but these should not be elevated into special 
varieties of purpura. 

There are five varieties of purpura, namely, purpura 
simplex, purpura senilis, purpura hemorrhagica, purpura 
rheumatica, and Henoch's purpura. It is convenient for 
us to preserve these varieties for a time, though the 
results of the latest studies seem to indicate that the 
third variety is but a more developed form of the first, 
cases of simple purpura having been seen to run into 
the hemorrhagic form. By Crocker and others the 
third variety is regarded as a form of erythema exudati- 
vum. It, too, has been seen to run into the hemorrhagic 
form. 

Purpura Simplex is the most common variety, and 
usually takes the form of petechia?, the lesions being 
round or oval, or irregular in shape, or even circinate. 
Duhring describes a case of the circinate form, as does 
Stel wagon. 1 The lesions appear suddenly, generally with- 

1 Jour. Cutan. and Gen.-Urin. Dis., 1887, v, 369. 



566 DISEASES OF THE SKIN 

out antecedent symptoms, and often at night. Like 
other varieties of purpura, the lower extremities are the 
most common seat of the eruption, especially their flexor 
aspects, but any part of the skin may be attacked, as also 
the mucous membranes. Crocker affirms that in children 
the lesions appear first upon the neck and upper part of 
the back. The lesions appear in crops, and most often 
are symmetrical. There may be but a single outbreak, 
and the whole disease may be at an end in a week or two, 
or it may be prolonged for many weeks by a succession 
of outbreaks. There is usually no constitutional dis- 
turbance, or a slight rise of temperature and malaise, and 
the only things the patient complains of are the spots, and 
perhaps some itching. Valvular heart lesions are not 
infrequent. Recovery is the rule. 

Purpura senilis is a form of purpura which occurs 
usually in persons over sixty years old who have senile 
skins. It occurs in red or telangiectatic hemorrhagic 
patches on the extensor aspects of the forearms, hands, 
legs, and feet; most often on the first two. It occurs 
spontaneously and is unattended by subjective symptoms. 
The lesions may be single or multiple but always isolated 
and ungrouped. They begin as macules which coalesce 
to form the patches. These are bean sized, round or oval, 
irregular, more or less sharply defined. In eight to ten 
days they begin to fade, and disappear in the course of a 
few months (Pasini). 1 

Purpura Hemorrhagica. — This form is also called 
morbus maculosus Werlhoffii, and land scurvy. It usually 
begins without prodromas, and is heralded by pro- 
nounced malaise, rise of temperature, headache, and 
perhaps convulsions. It differs from the previous 
variety in the more extensive hemorrhages that take 
place, ecchymoses forming rather than petechias, and 
in free bleeding from all the mucous membranes — 
nose, mouth, stomach, urethra, rectum, vagina. These 

1 Monatsheftc f. prakt. Dermat., 1906, xliii, 451. 



PURPURA 567 

are so copious and uncontrollable at times that the 
patient will literally bleed to death in a few hours. Sud- 
den death may also be caused by hemorrhage into the 
meninges and brain. An excellent study of this purpura 
fulminans has been made by Lockwood. 1 In his case 
there was a rise of temperature to 106.2° F. just before 
death, and the patient died in about sixty hours from the 
onset of the disease. Happily all cases of hemorrhagic 
purpura are not fatal. In them the bleeding is mod- 
erate in amount, and the patient is gradually restored 
to health. Relapses may occur. 

Purpura Rheumatica. — This is also called peliosis rheu- 
matica. It resembles purpura simplex in every way, 
excepting that the outbreak of the eruption is preceded or 
followed by pain in the joints accompanied by swelling, 
the malaise is more marked, and there is often rise of tem- 
perature. The eruption is frequently most abundant 
about the joints. The acute symptoms subside in two or 
three days, but relapses are frequent. True rheumatism 
may be present at the same time. Valvular heart lesions 
have been reported to occur after this variety of purpura, 
even without rheumatism. Rarely this variety may pass 
over into the hemorrhagic form. 

Henoch's Purpura, according to Osier, "is seen chiefly 
in children, and is characterized by relapses or recur- 
rences, often extending over several years; by cutaneous 
lesions, which are those of erythema multiforme rather 
than simple purpura; by gastro-intestinal crises — -pain, 
vomiting, and diarrhea; by joint pains or swelling, often 
trifling; and by hemorrhages from the mucous mem- 
branes. Any one or two of the above symptoms, may be 
absent; the intestinal crisis with enlargement of the spleen 
may be present and recur for months before the true 
nature of the trouble becomes manifest. The prognosis 
is, as a rule, good." 

Balzer and Galup 2 describe an annular purpura which 

1 Med. Rec, 1891, xxxix, 155. 

2 Bui. de la Soc. franc, d. derm, et syph., 190X, xix, 17. 



568 DISEASES OF THE SKIN 

begins as punctiform spots, or lentil sized, or linear. 
These slowly enlarge centrifugally into annular figures. 
On disappearing they leave slightly atrophic colorless 
spots. They occur symmetrically on the limbs, and 
sometimes secondarily on the trunk. 

Etiology. — Purpura may occur at any period of life, 
in both sexes, and in the most varying conditions of health. 
There is no doubt that it occurs as a symptom in different 
diseases and cachexias; after the ingestion of certain drugs, 
and under other circumstances too numerous to catalogue 
here. To permit the escape of blood one or both of two 
things have occurred, namely, a change of the blood itself 
that allows of its passing through the walls of the vessels, 
or a change in the vessel walls themselves that permits the 
blood to pass through them. Purpura has been noted after 
the loosening of some artificial support to a part of the 
body, such as a tight bandage worn for a long time. 
It occurs not infrequently in old age. In both these 
conditions it is due to a weakening of the tone of the 
vessel. In the former case matters right themselves in a 
few days — a happy conclusion that cannot be anticipated 
in the latter case. Weakness of vascular walls may also 
be the cause of those somewhat rare cases of purpura 
without cachexia seen in infants. Other cases of purpura 
are due to small thrombi lodging in the smaller vessels. 
Some cases seem to be due to vasomotor or trophic nerve 
action causing either sudden alterations in the calibre of 
the vessels or degenerations in their walls. Recurring 
purpura has been noted about the point of greatest pain 
in neuralgia. 

The microbian and infectious origin of purpura has its 
advocates. Some authorities believe that purpura occur- 
ring in an infectious disease is due to microorganisms. 
Letzerich 1 published a brochure on this subject in 1889, 
in which he described the "bacillus purpuras hsemor- 
rhagicse Letzerich" as the cause of the disease. This 

1 Monatshefte f. prakt. Dermat., 1889, ix, 312. 



PURPURA 569 

has sharp angles and edges, is readily cultivable, and 
pure cultures injected into rabbits give rise to hemor- 
rhages either spontaneously or on slight trauma. His 
findings have been confirmed by others. There is a 
growing belief in the theory of auto-intoxication as a 
cause of some of the cases. 

Pathology. — It is in the corium that the hemorrhages 
chiefly occur, but the subcutaneous tissues are sometimes 
implicated. Examination of the blood shows irregular 
changes in the number of blood cells and in their form, as 
well as in the quantity of fibrin. 

Diagnosis. — The diagnosis of purpura is easily made. 
No other disease produces bright-red, slightly elevated 
lesions, the color of w T hich cannot be made to disappear 
under pressure. From flea-bites it is distinguished by the 
absence of a central punctum in the lesions. Purpura 
hemorrhagica bears a close resemblance to scurvy, but in 
the latter a dietary deficient in vegetables is a marked 
etiological factor ; there are also greater prostration, swell- 
ing of the gums, loosening of the teeth, and brawny 
swelling of the limbs. It is possible that further inves- 
tigations of scurvy may show that it is but a form of 
purpura hemorrhagica that has been modified by diet. 

Treatment. — In simple purpura there is not much to 
be done except to put the patient in as good a hygienic 
condition as possible, give proper attention to any cach- 
exia, administer ergot and iron, and relieve symptoms. 
In peliosis rheumatica and purpura hemorrhagica the 
patient should be kept absolutely quiet in bed, his diet 
should be of the most nutritious and easily assimilable 
kind, and ergot and iron administered. Calcium chlorid, 
15 to 30 (1 to 2) grains t. i. d. has been advised by Wright 
to increase the coagulability of the blood. It must be dis- 
continued after a few days. Of course, if there is hemor- 
rhage from the nose, vagina, or other mucous cavity, 
an effort must be made to stop the flow by means of a 
tampon, ice, hot water, or any method that experience 
has proved useful. Erogtin may be employed hypoder- 



570 DISEASES OF THE SKIN 

inically; and turpentine; dilute sulphuric acid; nitrate 
of silver in pill-form, \ to J of a grain three times a day; 
and other astringents have been found useful. Letzerich 
recommends for the local treatment of bleeding from the 



1$ — Tinct. ratanhiae, 10 parts. 

Tinct. iodini, 5 " M. 

of which 10 drops are to be taken in a wineglassful of 
water. For this purpose other astringents, as tannin, 
alum, and the like, may be used. Adrenalin should be 
tried in purpura hemorrhagica. 

Prognosis. — From the beginning of a case it is not 
possible to say how it will turn out, purpura simplex 
sometimes changing to the hemorrhagic form. We should, 
therefore, be very guarded in our prognosis. Most cases 
met with terminate favorably. Some apparently des- 
perate cases recover. 

Pustula Maligna. — Synonyms: Anthrax; Malignant 
pustule; (Fr.) Charbon; (Ger.) Milzbrand. 
. This is a disease of cattle, sheep, and horses, in which 
it is called splenic fever, and is due to local inoculation 
with the bacillus anthrax, often through the agency of 
flies. If the bacillus gains access to the internal organism, 
it produces a rapidly fatal general disease with no skin 
lesion. In the human, the exposed parts — face, hands, 
and neck — are the most frequent sites of the disease. In 
a day or two after inoculation the patient notices a burn- 
ing or itching of the affected part and the formation of a 
livid-red papule upon which a bulla or pustule soon forms. 
This ruptures, the red spot changes into a black gangren- 
ous eschar, the parts around it become indurated, edema- 
tous, of dusky-red hue, and studded with small vesicles or 
pustules. There are marked involvement of the lymph- 
atics and enlargement of the neighboring glands, that 
may suppurate. In favorable cases the slough separates 
and healing by granulation takes place. In fatal cases 
the gangrenous process extends rapidly, symptoms of 



RHINOSCLEROMA 571 

septic infection declare themselves, and the patient 
succumbs to the disease in from two to eight days. In 
all cases there is more or less constitutional disturbance. 

Diagnosis. — The diagnosis of malignant pustule is 
made mainly by the rapidity with which the disease 
develops; the presence of the gangrenous patch with the 
hard indurated tissues about it; and the severity of the 
constitutional symptoms. The finding of the bacillus will 
verify the diagnosis. 

Treatment. — The total excision of the diseased patch 
by means of a free incision is the most radical and effect- 
ual treatment for the disease. The injection of tincture 
of iodin, or of a 5 per cent, solution of carbolic acid under 
the eschar is a good method .of treatment. The hypo- 
sulphite or sulphite of soda, and large doses of quinin, 
are worthy of trial. 

Quinquaud's Disease. — See Folliculitis decalvans. 
Raynaud's Disease. — See Dermatitis gangrenosa. 
Recklinghausen's Disease. — See Fibroma. 

Red Gum. — "An obsolete term for various transitory 
eruptions in teething children" (Foster). Commonly 
this is miliaria rubra. 

Rhinophyma is the term used to designate that form of 
hypertrophic rosacea in which pendulous tumors develop 
on the nose. These may attain to so great a size that 
they hang down over the mouth. See under Rosacea. 

Rhinoscleroma. — Synonyms: (Fr.) Rhinosclerome; Peri- 
sarcoma. 

Symptoms. — This is an exceedingly rare disease that 
was first described by Hebra and Kaposi. It affects 
almost exclusively the nose and its mucous membrane, 
and assumes the form of flat or slightly raised, sharply 
defined, isolated or confluent, very hard, lobulated, elastic 
plates, tumors, or nodes which are painful on pressure. 
These lesions are located in the skin or mucous mem- 
brane of the septum of the nose, or in the aire nasi 



572 DISEASES OF THE SKIN 

and the neighboring parts of the upper lip. They can be 
raised from the underlying parts, but the skin is so infil- 
trated that it can move only with the growths. The 
color of the skin may be normal, or bright or dark- 
brownish red. It may look like a keloid or hypertro- 
phied scar. The contiguous skin shows no abnormalities 
whatsoever. The epidermis over the growths often shows 
rhagades, from which exudes a viscid secretion which dries 
into yellowish adherent crusts. 

Fig. 84 




Rhinoscleroma. 

The disease begins as a thickening and hardening of 
the septum of one or both alse without inflammatory 
reaction or pain. Slowly the nose becomes deformed, 
broad, and flat, and at last by progressive thickening of 
both septum and alee the nostrils become occluded. The 
process may involve the lips so that the opening of the 
mouth becomes greatly lessened, and may affect the gums. 
More frequently it proceeds backward along the nostrils 
on to the velum palati. The growth shows little ten- 
dency to ulceration or retrograde metamorphosis. At the 



RHINOSCLEROMA 573 

most superficial parts excoriations occur. Late in the 
disease the teeth may loosen and fall out, and the gums 
may atrophy. The disease begins in some cases in the 
pharyngeal vault. The epiglottis and larynx may be 
involved in the process, and aphonia, and suffocative or 
epileptiform attacks may occur. There is no constitu- 
tional disturbance, and the only subjective symptoms 
are those of discomfort on account of the interference 
with respiration. The disease is steadily progressive, 
shows no tendency to recovery, and recurs rapidly when 
the diseased parts are cut away. 

Etiology and Pathology. — It occurs in all social 
grades, and affects both sexes with about equal frequency. 
It usually begins between the fifteenth and fortieth years. 
It is most frequent in warm climates, and is specially 
prevalent in Austria and Russia. A bacillus has been 
found in the tissues by Frisch that is regarded as the 
cause of the disease. It is described as short, thick, 
ovoid, capsulated, in free groups and in cells. It is named 
bacillus rhinoscleromatis. The disease is a granuloma, 
the corium and papillary layers being densely infiltrated 
with small cells. In places there is very dense fibrous 
tissues. There is hardly any change in the epidermis. 

Diagnosis. — -The location upon the nose and upper lip 
alone, the ivory hardness of the growths, and their pro- 
gressive course without tendency to ulceration or soften- 
ing, will establish the diagnosis as against syphilis, epithe- 
lioma, and sarcoma. Keloid rarely occurs upon the nose, 
and never runs the characteristic course of rhinoscleroma. 

Treatment. — Treatment is very unsatisfactory. The 
growths may be excised or curetted away, but neither 
process will assure against a relapse. The nostrils may 
be kept open by means of sponge-tents, and the like. 
Besnier 1 recommends boring into the tissues with points 
of chloride of zinc for the purpose of giving passage to 
air. Pyrogallic acid, 10 per cent, in vaselin, and salicylic 

1 Ann. de derm, et de syph., 1891, ii, 603. 



574 DISEASES OF THE SKIN 

acid, 1 per cent, solution injected into the tumor, have 
been recommended as of value. Lustgarten treated one 
case with excellent result by the x-rays. 

Prognosis. — The prognosis is bad. The disease is 
progressive, and threatens life by suffocation on account 
of involving the larynx. 

Rhus-poisoning. — See Dermatitis venenata. 
Ringworm. — See Trichophytosis. 

Ritter's Disease. — See Dermatitis exfoliativa neonato- 
rum. 

Rodent Ulcer. — See Epithelioma. 

Rosacea. — Synonyms: Acne rosacea; Gutta rosacea seu 
rosea; Acne erythematosa; (Fr.) Acne rosee, Couperose, 
Rosacee; Rosee; (Ger.) Kupferrose, Kupferfinne, Kup- 
frigegesicht. 

A chronic disease of the skin, limited in most cases to 
the middle third of the face from above downward, and 
characterized by a diffused or patchy redness made up of 
dilated capillaries. 

This disease is very commonly called acne rosacea, but 
inasmuch as the papules that often occur with the disease 
are not true pustules it is best to drop the "acne" from 
its title. 

Symptoms. — Rosacea is one of the more common skin 
diseases and is peculiar in affecting, with few exceptions, 
only the middle third of the long diameter of the face — the 
forehead, nose, and adjacent portions of the cheeks, and 
the chin. The nose may be affected alone, and in many 
cases the forehead escapes entirely. The disease has three 
forms or stages. The first consists in a simple redness of 
the affected skin with more or less well-marked dilatation 
of the capillaries. In the second stage there is an added 
element of superficial papules and pustules, and perhaps 
nodules. In the third stage there is marked hypertrophy 
of the skin. The process may stop at any stage. A 
seborrhea may complicate the disease, Unna even claim- 



ROSACEA 



575 



ing that his seborrheal eczema is the first stage of all 
cases of rosacea. 

The first stage varies in degree. At first there may be 
faint flushing of the skin, as after the ingestion of hot 



Fig. 85 




Rhinophyma. (Courtesy of Dr. H. Fox.) 

fluids, exposure to cold, and the like. This being re- 
peated, permanent dilatation of the capillaries takes place. 
The dilated capillaries are not evident all over the patch. 
The greater part of the patch may present an even red- 
ness. The border of the patch is ill defined, and no 



576 DISEASES OF THE SKIN 

matter how fiery red the color may be the skin feels cool 
to the touch. This is because the congestion is passive on 
account of a sluggish circulation. In some cases, how- 
ever, there may be but little general redness, only a 
number of dilated capillaries. These telangiectases are 
best seen on the nose. In some cases there may develop 
a congestive seborrhea or even an erythematous eczema 
which, yielding to appropriate remedies, leaves behind 
an undoubted rosacea. 

The second stage may develop from the first after the 
latter has lasted a considerable length of time, or be almost 
coincident with it. The number of papules and pustules 
may be considerable, and the tubercles large. If so, the 
amount of redness will be great. The peculiar feature of 
the pustules is their superficiality. They are usually quite 
small, say of pinhead size, and when pricked give exit to 
but a small drop of thin pus. The tubercles are enlarged 
or clogged sebaceous glands, but all these lesions are but 
secondary to the chronic hyperemia, and not primary, as 
in acne. There may also be comedones and true acne 
scattered over the face. 

While the majority of cases never go beyond the second 
stage, in some cases the continued and excessive hyper- 
emia leads to an increase of connective tissue, and the 
nose, tip and sides, becomes converted into a lobulated 
mass of tissue, sometimes so great as to form pendulous 
tumors hanging down over the mouth. This last con- 
dition is known as rhinophyma. The whole nose is of 
deep-red or purple color, and studded over with crater-like 
openings, leading down into the thickened mass. At times 
ulceration occurs in these crypts and causes additional 
annoyance and deformity from destruction of tissue. 

While in the vast majority of cases the middle third of 
the face alone is affected, in some cases the whole face 
becomes red, and the redness may extend down upon the 
neck. Rosacea is seen at times on the scalp of bald- 
headed persons just above the forehead. 

Etiology. — The cause of the disease is probably a 
vasomotor reflex neurosis. Schwimmer regards it as a 



ROSACEA 577 

trophoneurosis; Unna, as a seborrheal dermatitis. It 
occurs in adult life, most frequently after the twenty-fifth 
or thirtieth year, though it may occur even at puberty. 
There is no connection between it and acne. While many 
patients will tell you that they had "pimples" when 
young, as many will inform you that they have always had 
a good complexion until the rosacea began. Women are 
more frequently affected than men. Digestive disturb- 
ances are a very common cause of the disease, and the 
trouble may be located either in the stomach, intestines, 
or accessory digestive organs. Drinking of alcoholics 
will undoubtedly cause it, on account of producing both 
gastric catarrh and reflex dilatation of the facial vessels. 
The inordinate use of strong tea acts in the same way, 
and probably gives rise to as many cases as does alcohol. 
Exposure to the weather or to extremes of temperature 
will cause rosacea without digestive disturbances, but 
when combined with the latter leads on to the most bril- 
liant examples of it. Constipation, menstrual derange- 
ments, anemia, chlorosis, gout, lithemia, the menopause, 
each one has been noted in connection with rosacea. The 
use of cosmetics has been followed by it. Various mor- 
bid conditions of the mucous membrane of the nose 
have been found in connection with it. Tight lacing is 
frequently followed by rosacea. 

Pathology. — In the first stage there is dilatation of 
the bloodvessels in the cutis. In the second stage this is 
more pronounced, and the corium is slightly thickened 
and edematous in places. In the third stage there is in 
addition enormous hyperplasia of the connective-tissue 
elements of the cutis, and the sebaceous glands are 
enlarged (Elliot). 

Diagnosis. — When we meet with a case of redness of 
the skin, with or without papules, pustules, or tubercles, 
that is limited to the middle third of the vertical diameter 
of the face, it is probably one of rosacea. It differs from 
acne in its limited area, the superficial character of the 
pustules, the absence of comedones, and the capillary dila- 
tation. Lupus erythematosus may occur in the same loca- 
37 



578 DISEASES OF THE SKIN 

tion, but in it we do not find the dilated capillaries; but 
we do find thickening of the skin, adherent scales with 
prolongations from their under side, a sharply defined, 
slightly raised border to the patches, and, if the disease 
has lasted any time, more or less delicate cicatricial tissue. 
In its early stage the diagnosis is not always easy. Lupus 
vulgaris should not confuse us, as in rosacea there is an 
entire absence of the characteristic apple-jelly-like tuber- 
cles of lupus. The tubercular syphilid may resemble 
rosacea in its second or third stage, but soon it undergoes 
softening and ulceration — processes that do not occur in 
rosacea. Moreover, it is not symmetrical, but occurs 
in the form of groups of tubercles, presents no telangi- 
ectases, and evidences of other syphilides are usually to 
be found. Erythematous eczema burns and itches, the 
skin is somewhat swollen and scaly, and feels harsh 
and leathery. Sometimes an eczematous condition 
complicates a rosacea, and the latter declares itself only 
when the former is cured. 

Treatment. — In order to treat rosacea successfully we 
must first endeavor to remove the cause. We must 
inquire as to the patient's general condition. Then we 
must address ourselves to the regulation of any deranged 
function. We must stop the use of alcoholics in any 
form, and the ingestion of all hot fluids, such as tea, 
coffee, and soup. All these tend to produce dilatation of 
the bloodvessels of the face and to keep up those conditions 
we wish to remove. The patient's diet should be care- 
fully regulated, so as to make digestion as easy as pos- 
sible. The drinking of a half pint of hot water before 
meals is to be advised. Medicinally, tincture of nux 
vomica, the mineral acids, or alkalies are to be adminis- 
tered q. r. n. Nux vomica has often seemed to render 
good service, even without there being marked digestive 
disturbance. Salol is a good remedy in many cases of 
intestinal fermentation. Ergot or ergotin proves useful 
in some cases, either with or without uterine disturbances. 
Ichthyol is commended by Unna. The ammonia sulphate 
is the preparation he advises, and it is best given in 



ROSACEA 579 

capsules to cover the taste. The dose is 3 drops two or 
three times a day. Ichthalbin, 15 grains (1) t. i. d., has 
been substituted for ichthyol, and some good results 
from its use have been reported. Whitfield advises 
the administration of 1 to 2 grains of menthol after meals, 
or half a teaspoonful of syrup of codeia in a wineglass 
full of water before meals. 

The local treatment is important in hastening a cure, 
but is not of itself curative in well-marked cases of reflex 
rosacea. The patient must be instructed to protect the 
skin from the action of wind and weather, by either 
applying some ointment, such as cold cream, or a lotion, 
such as the calamin lotion, or a powder, such as corn- 
starch, before venturing out of doors. The face should 
be bathed with hot water every night before going to bed, 
the water being as hot as the skin can stand without burn- 
ing, and it should be sopped on for about ten minutes, 
fresh supplies of hot water being added from time to time 
so as to maintain a uniform temperature. This is benefi- 
cial because the primary dilatation of the vessels caused 
by it is followed by contraction. After the bathing the 
following lotion may be applied: 



-Zinc, sulphat., 








Potass, sulphuret., 


aa 5j 


aa 


4 


Aquae rosas, 


ad giv 


ad 


120 



M 

It is, perhaps, as good as any application we can make. 
Van Harlingen gives another good one as follows: 



-Sulphur, praecipitat., 


5J 


4 




Pulv. camphorae, 


gr. v 




38 


Pulv. tragacanth., 


gr. x 




66 


Aquae rosae, 








Liq. calcis, 


aa 5J 


32 





M. 

Resorcin 5 or 10 per cent, in water or dilute alcohol 
may be advised. If any one of these lotions is used several 
times a day it may cause the skin to peel off after a few T 
days. If so, it is to be stopped and a cooling lotion or 
ointment used until the peeling stops, when the lotion 
may be used again. It is desirable in obstinate cases to 
cause the skin to peel off. 



580 DISEASES OF THE SKIN 

Instead of lotions, sulphur ointment (5 j to § j) (or 4 to 32) 
or the white precipitate ointment may be used, or simply 
powdered sulphur. In obstinate cases Vleminckx's solu- 
tion may be used. It is composed as follows: 



1$ — Calcis, 3iv 16 

Sulphur, sublimat., 5j 32 

Aquae destillat., gx 320 



M. 



Boil together with constant stirring, until the mixture 
measures 6 fluid ounces (186), then filter. This is to be 
diluted four or five times at first, and used at night only, 
followed by cold cream in the morning. The dilution is 
to be lessened by degrees. 

Ichthyol, in 5 to 50 per cent, strength in aqueous 
solution, has been highly extolled by Unna and others. 
W. J. Munro 1 recommends painting the nose, after 
bathing with hot water, with a solution of adrenalin, 
made by dissolving one of Borroughs & Welcome's 
tablets in 1 dram (4) of water with a little camphor. This 
first causes redness, followed in five minutes by paleness. 
During the day the lotio alba is to be used; and from 2 
to 6 of the tablets of adrenalin are to be taken by the 
mouth, stopping them if vertigo or nausea is caused. 

G. W. Wende 2 reports a cure by using galvanism, 
placing the anode over the abdomen and the cathode on 
the face. 

If the case is highly inflammatory when first seen, our 
first attempts should be in the direction of reducing the 
inflammation by means of soothing ointments. After a 
few days we can begin the treatment of the rosacea. 

Surgical procedures are necessary to hasten the removal 
of pustules, and to destroy dilated vessels and hypertro- 
phic tissue. Pustules are quickest removed by the 
curette, or acne lancet as in acne. Dilated vessels are 
best destroyed by electrolysis with the electric needle 
attached to the negative pole, introducing it perpendicu- 
larly into the vessel at one or more points or longi- 

1 Austral. Med. Gaz., 1900, xix, 496. 

2 Buffalo Med. Jour., 1898-9, xxxviii, 254. 



ROSACEA 581 

tudinally in its course, and letting it remain for a few 
seconds until the vessel appears as a white line. The 
method of using electrolysis is more fully described 
under hypertrichosis. It is often necessary to repeat the 
operation several times before the vessel is destroyed. 
The operation is prone to leave punctate scars. The 
thermocautery may also be used in the same way. Mul- 
tiple scarification is most useful in reducing red patches. 
It may be done by means of a scalpel, making parallel 
lines near together and through the skin, and then a 
second series over these; or a multiple scarifying-knife, 
as sold in the shops, may be used for the purpose. H. 
Fournier 1 advises the use of a flat needle rounded at its 
end and bevelled on its under side. The vessels are to 
be cut obliquely to their long axis, while the skin is 
put on the stretch. After scarifying, bleeding should be 
encouraged for a few moments by the application of warm 
water. Then the surface should be swabbed over with a 
solution of carbolic acid, 2 drams (8) to the ounce (32) of 
glycerin and water. This will check the bleeding and 
constringe the vessels. No after-treatment is needed, as 
a rule. If reaction tends to go too far, a soothing oint- 
ment may be applied. The operation should be repeated 
once every week or two. Multiple punctures may be 
made with the acne lancet, the subsequent treatment being 
the same as after multiple scarifications. It is astonish- 
ing to see how rapidly the redness will be reduced in 
many cases, and this without deformity being caused. 
Multiple scarifications may be employed for the reduc- 
tion of tuberculated masses — rhinophyma — but a plastic 
operation is the most satisfactory method of treatment. 
Both the high frequency current by sparking and the 
Rontgen rays have been used with benefit. The latter 
clear up the acne element and reduce the connective-tissue 
overgrowth, but will not remove the dilated vessels. 

Prognosis. — In cases of rosacea arising from exposure 
to weather in drivers and sailors, and in those following 
similar pursuits, we cannot expect to effect a cure, as the 

1 Jour. mal. cut., etc., 1895, vii, 257. 



582 DISEASES OF THE SKIN 

patients cannot do the one thing necessary — give up their 
occupations. In most all other cases we can promise great 
amelioration of the annoying redness, and in many we can 
effect a cure ; but we had best not attempt to treat a patient 
who will not follow our directions as to diet and hygiene. 

Rotheln, Rubella, or German measles, is a mild con- 
tagious disease that resembles measles, but differs from it 
in the mildness of all its symptoms, in the lighter color 
and smaller size of its lesions and in the absence of the 
crescentic arrangement of them. It is seen mostly in 
children. Its period of incubation is from one to three 
weeks. Its period of invasion is from a few hours to a 
day or so, and marked by slight malaise and fever, 
sometimes so slight as to be overlooked. The eruption is 
not so blotchy as measles, the lesions being pale red, 
macular or maculo-papular, varying in size from a pin- 
head to a lentil, and the catarrhal symptoms are absent 
or but slight. Swelling of the glands of the neck is a 
symptom that may or may not be present, but when 
present is characteristic. The lesions may take the form 
of small papules, and assume rather a brownish than a 
red color. There may be very few of them. The eruption 
is often itchy, and the lesions may occur on the mucous 
membranes. The duration of the disease is but a few 
days, and the health of the patient may be undisturbed. 
Desquamation may occur. It differs from scarlatina in 
the mildness of all its symptoms, and in the absence of 
the diffuse scarlet eruption of the latter disease. The 
absence of catarrhal symptoms, and mildness of the 
general symptoms taken in connection with the enlarge- 
ment of the cervical glands distinguish it from measles. 
The treatment is purely symptomatic. 

St. Anthony's Fire.— See Erysipelas. 
Salt-rheum. — See Eczema. 

Sarcoid. — According to J. Darier 1 this name was first 
proposed by Kaposi who included under it granuloma 

1 Monatshefte f . prakt. Dermat., 1910, 1, 419. 



SARCOID 583 

fungoides, lymphodermia perniciosa, and sarcoma. As 

described in the literature the disease presents in lour 
types, namely: (1) Boeck's Multiple Benign Sarcoid. (2) 
Darier's Subcutaneous Sarcoid. (3) The Nodular Sarcoid 
of the Extremities. (4) The Spiegler-Fendt Type. 

I. Boeck's Multiple Benign Sarcoid, or Miliary Sar- 
coid.— Of this there are three forms. (1) The tubercular 
form, which occurs in bean- to nut-size, round, oval, or 
irregular shaped nodules, of which there may be few or 
many. (2) The papular form, which occurs in hemp- to 
bean-size papules, of which there may be hundreds or 
thousands. (3) The infiltrated form, which occurs in 
patches which are ill defined, hard, and slightly or not 
at all raised. 

The disease may begin suddenly as a diffused, slightly 
pruritic, edematous redness of the skin, which disappears 
in a few days, and leaves one or more hard lesions of the 
skin. Or a papule forms deep down in the skin, which 
grows slowly, and raises up the skin into a firm papule 
or nodule. These may last months or years. At first 
they are red; later they become reddish, violet, or yellow- 
ish, and at last brownish. Under the diaskop they are 
less pronounced than those of lupus, and often appear as 
if composed of small hemp-seed-sized bodies of yellowish 
or gray color. When they undergo retrogression they 
sink in the middle, are covered with a net work of tel- 
angiectases, and surrounded by a yellow, often scaly 
border. After they disappear there remains a small pig- 
mented spot, or one that is atrophic with telangiectases. 
They never soften or ulcerate. The lymphatic glands may 
or may not be swollen. There are no subjective symptoms. 
There may be but a single tumor. Relapses are frequent. 

The most usual sites of the disease are the face, back, 
shoulders, and extensor aspect of the arms. They may 
occur on the scalp, buttocks, or legs. The palms and soles 
are spared. They are moderately symmetric in distribution. 

They may begin about scars. Women are more often 
affected than men, and most of the patients are tuber- 
culous. Cases have been noted between the thirteenth 



584 DISEASES OF THE SKIN 

• 

and forty-fifth year of age. Histologically the tumors 
seem to be a chronic, infective granuloma. 

They must be differentiated from sarcoma, leukemia 
cutis, syphilis, leprosy, and. tuberculosis. Lupus miliaris 
has transparent papules with cheesy centres, is inoculable 
in animals, and reacts to tuberculin, while those of 
sarcoid do not. Lupus erythematosus tuberosus is 
differentiated by biopsy. Lupus pernio is a seasonal 
disease, its lesions are softer and of different color, and 
neither clinically nor microscopically sharply defined. 

The best treatment consists in arsenic, or in calomel 
injections. 

II. The Subcutaneous Sarcoid of Darier. — This is a com- 
paratively rare disease. It consists in a subcutaneous, 
painless, creeping, new formation inclined to unlimited 
growth, to generalization, and to softening or ulceration, 
without effect on the general health. The disease begins 
gradually. The lesions are nodes, which are sometimes 
isolated, round or oval, hazel-nut to walnut size; sometimes 
they join together to form stripes that follow the course 
of bloodvessels, or uneven patches 15 to 20 cm. long, 
that lose themselves in the surrounding skin. The number 
of nodes vary. They are hard and painless, and either 
movable on the underlying parts, or attached to the skin. 
Their color is reddish, lilac, or slate. The disease occurs 
specially in the region of the ribs, on the shoulders, 
back, sides, or haunches, and is symmetrical. It is seen 
only in adults, and is a tuberculid, reacting to tuberculin. 

The disease is located in the subcutaneous tissue and 
sends projections into the cutis. It consists of epithelioid 
and connective-tissue cells, and lymphocytes intermixed 
with typical or half-developed giant cells. About the 
new formations lie defined cell heaps of the same kind 
of cells. The fatty tissue is atrophied and sclerosed. 

This form of sarcoid differs from the first type in the 
appearance, size, subcutaneous location, and typography 
of its lesions. 

III. The Nodular Sarcoid of the Extremities. — This 
form is probably the same as erythema induratum. The 



SARCOMA 585 

eruption consists in circumscribed thickenings and harden- 
ings of the cutis and subcutaneous tissues, which are 
painless, and seldom soften or ulcerate. They appear 
in crops, beginning as pea- to hazel-nut-sized subcutaneous 
tumors, either movable or adherent to the skin. After a 
time they become violet, lilac, red, or slate color. They 
run together and form patches which may be depressed 
in the centre. They may last months or years, but 
ultimately disappear and leave no trace in the skin. 
They are more common than the other types of sarcoid, 
and are located on the extensor aspects of the arms and 
legs. They occur both in the young and old, but espe- 
cially in females. It is difficult to diagnose them from 
tuberculous gummas excepting that the latter are more 
virulent and richer in tubercle bacilli. 

IV. The Spiegler-Fendt Type. — In this form the erup- 
tion consists in red or lilac, flat, or prominent nodes which 
are located deep in the skin and may unite to form large 
patches. They occur principally on the trunk, are more 
or less attached to the skin, painless, and may or may 
not ulcerate. They run a rapid or slow course and may be 
fatal. It is not a tuberculid and is cured by arsenic. 

Sarcoma.— We are here interested in sarcoma of the skin 
alone. Sarcomas may be primary in the skin, but most 
often they are secondary. They form variously sized 
tumors, but tend to run a malignant course, multiplying 
more or less rapidly, breaking down, affecting internal 
organs by metatasis, and killing the patient in a few 
months or years. There are three types of sarcoma, 
namely, the round-cell sarcoma, the small-cell sarcoma, 
and the melano- or pigment sarcoma. Sarcomas may be 
divided into two varieties — the pigmented and the non- 
pigmented. Very commonly sarcomas are of mixed type. 

Primary melanotic sarcoma or melanoma originates 
frequently from an irritated nevus or other pigmented 
lesion, but may occur independently. Regions rich in 
chromatophores show a proneness to the disease, such 
as the anal and genital. At first it is always single and 



586 DISEASES OF THE SKIN 

small. It tends to enlarge and attain the size of a nut. 
In shape it is oval or spherical. It is nearly always sessile. 
Its color is dark blue or black. It is very hard to the 
touch. It may remain stationary for a long time, but 
eventually new tumors will appear, either about the 
original one or at distant points by way of the lymphatics. 
Some of the original tumors will disappear, while new 
ones appear; some will break down and form irregular 
ulcers whose floors are black and uneven, and secrete a 
thick, melanotic liquid, or a little pus, or almost solid 
black matter. The neighboring lymphatic glands become 
enlarged, and may break down and discharge the same 
inky black fluid. A large lobulated mass may be formed 
by the coalescence of a number of smaller lesions. The 
viscera become involved, and death soon occurs. There 
may be melanemia and melanuria. 

A rare form of melanotic sarcoma is described by Hutch- 
inson as melanotic whitlow, which at first is a chronic 
onychitis, the border of which looks like a lunar-caustic 
stain. It very gradually develops into a fungating tumor, 
slightly pigmented. The nail is shed, and generalization 
occurs (Crocker.) 

Non-pig wiented primary sarcoma may be generalized or 
localized. The generalized form begins usually upon the 
extremities, and causes upon the hands and feet a peculiar 
hard edema, accompanied by tension of the skin, and 
perhaps itching or pricking. It may begin as brownish- 
red, livid, purple, or blue patches, upon which pinhead- 
sized nodules appear, which gradually enlarge. In some 
cases little, infiltrated, isolated, blue or reddish-brown 
nodes will form. Sometimes the first appearance will 
be a diffused cyanotic patch, which later will become a 
bossy elevated patch. When the disease is fully developed 
the hands and feet are thick, deformed, infiltrated, as 
firm as cartilage, brown or blue with a red tint. The 
skin is glossy, scaly, uneven. The nodes may be raised, 
pedunculated, or ulcerated. Similar lesions are found 
upon the rest of the body, though rarely on the trunk. 
They may remain stationary, disappear, fall off, multiply, 



SARCOMA 



587 



ulcerate, or, finally, involve the mucous membranes and 
cause death. 

The localized form develops ordinarily from an irritated 
nevus, and is most often encountered on the extremities. 
It forms a hard, wrinkled tumor, which may ulcerate. Its 
color is usually that of the normal skin, though it maybe red. 
It may grow to be the size of an orange or take on a mush- 



FlG 




Multiple idiopathic hemorrhagic sarcoma. 

room-like form. It may not generalize for a long time, or 
it may do so spontaneously or after an attempt at removal. 
To this class of tumors Hutchinson's recurrent fibroid 
of the skin belongs. As described by him, "it begins 
usually on the lower extremities, grows slowly at first, 
but recurs rapidly and persistently after removal, however 
wide the incision, and ultimately generalizes, fungates, 
forms blood cysts, and destroys the patient." 



588 DISEASES OF THE SKIN 

Sarcomas are very vascular, and are subject to profuse 
hemorrhage when injured or when they ulcerate. 

Under the name of idiopathic multiple hemorrhagic sar- 
coma a disease was first described by Kaposi. It occurs 
in adults, and begins as an edema of the hands, feet, and 
face, with more or less pruritus. Later dark-blue or 
purplish spots appear deep in the skin, which after a time 
form raised nodules, which may be sessile or pedunculated, 
but are always dark blue or purple. They vary in size up 
to a cherry or larger, or may be isolated or grouped. 
They are tender, and the patient may experience more or 
less pain. The extremities or face become elephantiasic in 
appearance, and covered with scales, and more or less 
rugous. The tumors may remain for a long time or dis- 
appear, or, rarely, ulcerate. The color of the tumors is 
due to vascular development. The disease is chronic in 
its course, and may last for fifteen or twenty years without 
affecting the patient's health, or the patient may die 
after a few years by extension of the disease and the 
involvement of the mucous membranes and internal 
organs. The disease may extend up the limbs to the 
trunk. Recovery may take place. 

Etiology. — We know very little in regard to the 
etiology of sarcoma. It occurs at all ages, some of the 
most malignant cases being seen in childhood. Brocq 
says that the localized non-pigmented sarcoma is most 
frequent in robust men of forty to sixty years. Piffard 
gives the ages at which they are most prone to occur as 
before the fifteenth and after the forty-fifth years. The 
Kaposi type is most often seen in men. The Jewish 
race is especially prone to it. It occurs in Russia and 
Italy more frequently than elsewhere, and in those who 
are much exposed to vicissitudes of wind and weather 
and live in bad hygienic surroundings. It is possible that 
all types may be due to infection, but the etiology of the 
disease is obscure. 

Pathology. — Sarcomas of the skin are histologically 
identical with sarcomas of deeper parts. They are 
connective-tissue tumors in which the cellular elements 



SARCOMA 589 

greatly predominate in bulk over the intercellular sub- 
stance. In this respect the tumors are comparable to 
embryonic connective tissue. The structure and form of 
the cells vary in different sarcomas, and the inter- 
cellular substance may be very scanty and of delicate 
structure in one tumor, and in another approach in 
quality and appearance the frame work of normally 
developed connective tissue. It is from these variations 
in the cells and intercellular substance that the tumors 
are numerously classified as simple sarcomas including 
the spindle and small and large round-celled sarcoma, 
and the lympho- and fibrosarcomas; organized sarcomas 
including the alveolar sarcomas or endotheliomas, and 
the angiosarcomas; and lastly those sarcomas character- 
ized by secondary changes in the cells or ground substance, 
among which the form of greatest dermatological import- 
ance is the melanosarcoma. In any of these the usual 
various retrogressive changes may occur, such as fatty, 
colloid, or hemorrhagic degeneration, caseation, necrosis, 
ulceration, etc. 

Melanotic sarcomas are vascular small or large round- 
celled, or more often spindle-celled tumors, with sometimes 
a giant cell here and there, and characterized by the pres- 
ence of abundant intra- and intercellular, granular and 
diffuse pigmentation. It has been recently demonstrated 
that many malignant pigmented tumors, arising from pig- 
mented moles and nevi, and formerly classed as melanotic 
sarcomas, are in reality carcinomas. 

In idiopathic multiple hemorrhagic sarcoma the cells 
are round or fusiform, and there is a rich network of 
vascular sinuses and thin-walled bloodvessels. Hemor- 
rhagic areas are scattered throughout the growth, and 
deposits of pigment derived from the extravasated blood. 
All the pigmentation is due entirely to the capillary 
hemorrhages. Involution, when it occurs, is through 
destruction and resorption of the tumor cells and pigment, 
with concomitant connective-tissue organization. 

Diagnosis. — The diagnosis of sarcoma is generally 
easy, but at times it is difficult. The pigmented forms 



590 DISEASES OF THE SKIN 

are usually readily recognizable by their color and fre- 
quently by their origin in a pigmented nevus. The non- 
pigmented single sarcomas may be distinguished from 
epithelioma by its feel, which, though firm, lacks the hard- 
ness that is characteristic of cancer. Fibromas are not so 
firm as are sarcomas, are more commonly pedunculated, 
and show no tendency to degenerative changes. Mycosis 
fungo'ides has a primary eczematous stage; its tumors are 
of a brighter red, and they come and go, and undergo 
various changes much more rapidly than do sarcomas, 
and pruritus is pronounced. 

Treatment. — Excision of a single non-pigmented sar- 
coma is often curative. In multiple sarcoma, and in 
the melanotic variety, operative interference is usually 
not only not curative, but has often seemed to hasten 
generalization. Kobner and others have used hypodermic 
injections of arsenic with brilliant results in some cases. 
Kobner used Fowler's solution of half strength, and 
injected 2| to 4 drops of it once a day. After three 
months the dose was increased to 7 J and then to 9 drops. 
Others have tried arsenic without effecting a cure. Still it 
is worthy of trial, as it may cure the disease if it is well 
borne by the patient. Inoculation by the toxin of the 
streptococcus has cured some cases, but its use is not with- 
out danger to the life of the patient. The x-rays will 
cause the disappearance of the tumors in some cases, 
but they are prone to relapse. Wallhauser 1 has reported 
the disappearance of the tumors in multiple hemor- 
rhagic sarcoma after four to six months' use of com- 
presses of bichloride of mercury, 1 to 2000, and after 
a while 1 to 500. 

Prognosis. — This is always grave. The course of the 
disease is nearly always from bad to worse, though the 
fatal result may not be reached for many years. Especially 
is this the case in multiple hemorrhagic sarcoma. Mela- 
notic sarcoma is more rapidly fatal than is the ordinary 
form. 

i Jour. Amcr. Med. Assoc, 1909, liii, 1608. 



SCABIES 59 1 

Scabies. — Synonyms: The Itch; (Fr.) Gale; (Gr.) 
Kratze. A contagious disease of the skin due to its 
invasion by the acarus scabiei, and characterized by 
excessive itching, worse at night, and by excoriated 
lesions, pustules, and cuniculi upon the anterior face of 
the wrists, between the fingers, on the breasts of females, 
the penis of males, and about the umbilicus of both sexes. 

Symptoms. — The popular name of scabies, which is the 
Itch, gives us at once one of the marked features of the 
disease. Itching is always present in it. While it may 
be somewhat in abeyance during the day, it is hardly ever 
absent, and at night in bed it is so bad, in susceptible 
individuals, that sleep is well-nigh impossible. The 
itching gives rise to scratching, and the scratching to the 
secondary symptoms of the disease — scratched papules 
and eczematous patches. 

The first thing that the patient notices is that his skin 
itches. To relieve this he scratches, and sooner or later, 
according to the resistance of his skin, he produces pin- 
head-sized excoriations. Later, the irritation continuing, 
eczematous patches may result. When he presents 
himself to the physician, the latter will find on examina- 
tion excoriations due to scratching, and he will notice 
that the lesions are located principally between the 
fingers, on the anterior surface of the wrists and somewhat 
on the forearms, about the axillae, upon the breasts 
about the nipples in women, upon the male genital 
organs, about the umbilicus and lower part of the ab- 
domen, and often upon the buttocks of both sexes, 
and, in children especially, upon the anterior surfaces 
of the ankles and between the toes. In adults, these 
latter situations are not so frequently affected. Closer 
examination may be rewarded by the discovery of the 
pathognomonic sign of scabies, namely, the cuniculus, 
or burrow, which is usually found most readily on the 
inner border of the hand, on the inside of the fingers, 
and on the penis. It forms a delicate, slightly raised, 
whitish or grayish, wavy, often bowed line, from one- 
eighth to one-half an inch in length, and having a white 



592 DISEASES OF THE SKIN 

speck at one end which marks the place where the itch- 
mite is. These are not always to be found; indeed, 
in most cases they are difficult to find, because they 
are broken up either by the occupation of the individual, 
by the use of soap and water, or by scratching. In 
people with delicate skin the burrowing of the itch- 
mite will set up an inflammatory process, and papules, 
vesicles, and pustules will form, quite independently of 
the scratching. 

While the regions mentioned are the ones always 
affected in well-marked cases, variations in the extent of 
the disease are observable. In some cases the hands are 
free, and but few lesions are present anywhere. Here, 
if it is a male, the crucial test will be the examination 
of the privates, where a scratch mark or a burrow will 
be found almost without fail. In other cases hardly any 
part of the body will be free from excoriations, pustules, 
or eczematous patches, excepting the face, which is 
affected only exceptionally, and then nearly always in 
children. In these bad cases furuncles and large ecthy- 
matous pustules join themselves to the already multi- 
form eruption of scabies. Urticaria is also present in 
some cases, its wheals being interspersed among the 
other lesions. Should some intercurrent fever arise, 
the symptoms of scabies will subside, to reappear when 
the fever is past. The so-called Norwegian itch is only 
a very much aggravated form of the disease, on account 
of the want of personal cleanliness of the people. The 
face in this form may be affected, the nails split and 
shed, and the palms and soles covered with thick crusts. 

Etiology. — Scabies is due to the irritation set up by 
the acarus scabiei and by the scratching employed to 
relieve the same. The vesicles, papules, or pustules 
about the burrows are due directly to the acarus; it may 
be on account of some irritating substance secreted by it. 
The disease is contagious, but requires prolonged contact, 
as by holding the hand or sleeping with an infected 
person. It is very rare for it to be communicated to a 
physician in examining a patient. 



SCABIES 593 

According to Greenough, 1 it is most prevalent between 
the ages of five and thirty, and comparatively rare after 
the fiftieth year. This, he thinks, is due to the fact that 
in advanced life the epidermis becomes harder and dryer, 
and forms a less suitable habitat for the acarus. A few 
years ago the disease was not common in this country, 

Fig. 87 




Acarus scabiei. Back. 

but now it is an every-day occurrence to meet with new 
cases in our dispensaries, and not an infrequent one to 
meet with it in private practice. 

Pathology. — The acarus scabiei is very small, being 
barely visible to the naked eye, the female being but one- 
sixtieth to one-eightieth of an inch long, and the male 
still smaller. Its width is about two-thirds of its length. 
It has eight legs: — four on each side of its head, to which 

1 Boston Med. and Surg. Jour., Sept. 23, 1886. 
38 



594 



DISEASES OF THE SKIN 



suckers are attached, and four posteriorly, to all of which, 
in the female, bristles are attached; while in the male the 
inner ones are wanting in bristles, but provided with 
suckers for attaching himself to the female in copulation. 
On the back are a number of short bristles. A glance at 
Figs. 86 and 87 will describe the animal better than 
words. 

Fig. 88 




Acarus scabiei. Under surface. 



The impregnated female acarus having landed on the 
skin, soon stirs about, and having found a suitable place, 
it rests on its hind feet, takes an oblique position, pierces 
the skin, and bores a hole into which it forces itself. It 
lodges in the deeper layers of the epidermis, above, and 
sometimes in the mucous layer. It bores a burrow 
equidistant between the surface of the epidermis and the 
level of the papillae of the corium. Being prevented by 
the bristles on her back from 



moving backward, she 



SCABIES 



595 



moves forward, and lays her eggs. Her duration of life 
is from six weeks to two months, and during this time she 
lays some fifty eggs. These hatch out, reach the surface of 
the skin, the females meet the male, become impregnated, 



Fig. 89 




Burrow of scabies with acarus. (After Kaposi.) 

bore in their turn into the skin, and so keep up the process. 
As the thinnest parts of the skin are most easily punctured, 
it is in these parts that we find the lesions most commonly. 
The scratching often extends far beyond the sites of the 



596 DISEASES OF THE SKIN 

burrows. Fournier found that an acarus dies in seven 
days when immersed in cold water, in ten days when in 
warm water, in two to four days in a solution of green 
soap. He denies the commonly accepted view that the 
acarus is a night-prowler, though he allows that it is most 
active at night. 

Diagnosis. — The presence of pustules and scratch 
marks between the fingers, on the anterior face of the 
wrists, about the umbilicus, on the breasts in women or the 
genitals in men, is enough to make the diagnosis of scabies. 
If a cuniculus can be found, it will be corroborative 
evidence. Eczema is more patchy and is not so markedly 
limited to the characteristic locations of scabies. Pedicu- 
losis vestimentorum presents long, parallel scratch marks 
instead of the small excoriations of scabies, and their char- 
acteristic locations are over the shoulders, about the 
girdle, and along the outer and inner side of the limbs 
where the seams of the clothing come. The itching of 
scabies is worse at night, while that of pediculosis is most 
marked in the daytime. Urticaria is a general disease 
characterized by wheals, and shows no tendency to 
localize itself in certain regions. Should urticaria com- 
plicate scabies, the wheals will be disseminated while the 
lesions of scabies will be most marked in their character- 
istic locations. 

Treatment. — If the disease is recognized, there is no 
difficulty in curing it, though there are various methods 
employed. Perhaps the oldest and one of the most reli- 
able, though not the most rapid "cure," is to have the 
patient take a warm bath with soap and water, scrubbing 
himself thoroughly so as to remove as much of the old 
epidermis as possible. Then he should dry the skin with 
vigorous friction, and rub into every diseased spot 
ordinary sulphur ointment. When this is done he should 
smear the rest of the skin with the ointment, put on the 
same clothes, and go about his business. The rubbings 
with the ointment are to be repeated morning and night 
for three days, the patient wearing the same underclothing 



SCABIES 597 

by day, and bed- and night-clothing by night. At the 
end of three days another bath is to be taken, the clothing 
changed, and the patient should then present himself for 
examination. If fresh lesions are found, a second course 
should be taken, which most always will be sufficient. 
An artificial eczema is apt to be set up by the sulphur, 
and as eczema itself itches we must not take the con- 
tinuance of pruritus beyond the second course as evidence 
of the scabies not being cured. It is better to stop the 
sulphur for a few days, and put the patient upon a mild, 
protective dressing to his skin, such as vaselin and corn 
starch. If the itching grows worse instead of better, a 
third course of rubbing must be gone through with. In- 
stead of plain sulphur ointment we can add balsam of 
Peru, about half a dram to the ounce, or use the modi- 
fied Wilkinson's ointment, as follows : 



; — Sulph. sublimat., 










01. cadini, 


aa 


5iv 


aa 


16 


Cretse praeparat., 




3nss 




10 


Sapo viridis, 










Adipis, 


aa 


Si 


aa 


32 



M. 

S. Sherwell, 1 instead of using sulphur in ointment form, 
has the patient rub into the skin the dry sulphur powder 
and throw in between the sheets of the bed, a \ teaspoonful 
of the same. We have tried this plan in private practice 
with perfect success. The treatment in the St. Louis 
Hospital of Paris is a heroic one, but is said to cure in 
one hour and a half. According to Fournier, the patient 
is scrubbed violently for half an hour with green soap; 
then for another half hour the scrubbing is continued 
while he is in a bath; then he is rubbed with Helnierich's 
ointment : 

I^ — Potass, carbonat., §ss 16 

Sulphur, sublimat., gj 32 

Adipis, 5x 320 M. 

Now he puts on his clothes without removing the salve, 
and is discharged cured. 

1 New York Med. Jour., 1893, i, 432. 



598 DISEASES OF THE SKIN 

(3-naphtol in 5 to 10 per cent, strength in ointment or 
oil, is a good remedy, free from the sulphur smell, and 
not so irritating. Kaposi recommends it in the following 
form: 

1$ — /S-naphtol, 15 parts. 

Sapo. viridis, 50 " 

Cretse alb. pulv., 10 " 

Adipis, 100 " M. 

and Crocker says: "I can speak of it in the highest 
praise." It is well fitted for private practice. McCall 
Anderson extols styrax liquida with a double amount of 
lard. As the itch is very prevalent in Scotland, the 
doctor should know of what he speaks. Too free use of 
this remedy may cause a nephritis, so patients using it 
must be watched. Epicarin, 10 per cent, in ointment, is 
a recent remedy well spoken of. I have found it quite 
as irritating as is sulphur. 

For infants and young children, balsam of Peru is the 
pleasantest application we can make, it being rubbed in 
morning and night, either pure or diluted with sweet 
oil; or a mitigated form of sulphur ointment may be 
used. It is possible to cause constitutional symptoms by 
using the balsam of Peru, but this is rare. 

In all cases the clothing and bedding must be disin- 
fected — washable things by boiling, and woollen clothing 
by baking or by ironing with a very hot iron. All 
affected members of the family must be treated at the 
same time. An irritable condition of the cutaneous 
nerves sometimes lasts long after the scabies is cured 
and must not be mistaken for a still active itch. 

Prognosis. — The prognosis is always good, provided 
the applications are made thoroughly enough. 

Scarlatina. — Scarlet fever is an acute contagious erup- 
tive disease with an incubation period of one day to two 
or three weeks, with an average of eight days. It is a 
disease of children in the vast majority of cases, though 
adults are not exempt. It is characterized by a rapid 
rise of temperature at the beginning, which may reach 



SCLEREMA NEONATORUM 599 

102° to 104° F., redness of the fauces, a strawberry 
tongue, and the appearance of a fine punctate scarlet 
rash, which, first appearing on the neck, chest, and 
flexures of the joints, rapidly spreads over the whole 
body. The redness may be even over all, so as to 
give a boiled-lobster appearance to the skin; or the red 
points may be distinct, although close together. The 
redness usually disappears on pressure. Vesicles may 
appear. A great deal of constitutional disturbance and 
prostration with more or less soreness of the throat 
usually attend the eruption, but convalescence is well 
established in the second week in the uncomplicated 
cases. Abundant desquamation follows the subsidence 
of the eruption, which continues for days or weeks. 
Complications are frequent such as otitis media, rheu- 
matoid pains, abscesses of the neck, heart disease, and 
albuminuria. 

Diagnosis. — There is often a striking resemblance be- 
tween scarlatina and erythema scarlatiniforme, and some 
other erythemas. (See Erythema.) Measles has more pro- 
nounced catarrhal symptoms, its eruption is macular, not 
punctiform, and crescentic. 

Treatment is symptomatic, and addressed to any 
complicating disease. 

Sclerema Neonatorum. — Synonyms: Scleroderma neona- 
torum; Induratio telse cellulosse; (Fr.) Algidite progres- 
sive, L'endurcissement athrepsique; (Ger.) Das Sklerem 
der Neugeborenen. 

This happily rare disease was first differentiated from 
oedema neonatorum, according to Crocker, by Parrot, in* 
1877. It may be primary, but most often it is secondary 
to some exhausting disease, such as pneumonia or intes- 
tinal catarrh. It may be present at birth, and rarely 
occurs after the first ten days of life. It is characterized 
by hardness of the skin, which generally at first is cir- 
cumscribed and affects the legs. It may be diffused from 
the first, or it soon becomes so and extends to the lumbar 



600 DISEASES OF THE SKIN 

regions, back, chest, and so all over the body, becoming 
universal by the fourth day. It may begin on the face, 
and it may stop before becoming universal. It may be 
but slightly developed on the chest. At first the skin is 
pale and waxy; later, it becomes livid and cold, and the 
child looks as if frozen. The skin becomes attached to 
the underlying parts, smooth, tense, and does not pit on 
pressure. Movement is impossible for the child, and the 
body may be raised without bending a joint. When the 
face is affected it is impossible for the child to nurse. Its 
respirations are greatly reduced in number, its pulse falls 
to sixty per minute, its temperature is below normal, its 
breath is cool, and it dies within a week. The primary 
congenital cases are either stillborn or die in one or two 
days. Localized cases sometimes recover, the hardness 
of the skin disappearing. 

Etiology. — The cause of the disease is obscure. It is 
seen almost exclusively in foundling asylums and among 
the very poor. It is,- therefore, a disease of depressed 
vitality. Langer 1 regards it as the result of solidification 
of the fat, which in infants contains 31 per cent, of palmi- 
tin and stearin, that of adults containing 10 per cent. 
The fat in infants, he says, is nearly all concentrated in 
the subcutaneous tissues, where it is five times as thick 
relatively as it is in adults. Naturally, an infant's tem- 
perature is higher than an adult's. If it is lowered by 
any depressing cause, the fat may solidify. Solidifica- 
tion may take place also under the action of cold, or by 
oxidation, as in fevers, withdrawing some of the constit- 
uents of the fat. Parrot regards the disease as one of 
desiccation from the drain of a diarrhea, or the like. 

Diagnosis. — Sclerema neonatorum is differentiated 
from oedema neonatorum by being more general in its dis- 
tribution, by the skin being harder and more tense, and 
not pitting on pressure, and by the rigidity of the joints. 
Scleroderma occurs at a later age than does sclerema, and 

1 Wien. mod. Presse, 1881, xxii, 1375. 



SCLERODERMA 601 

the skin lacks the coldness of the latter. There are no 
other diseases with which sclerema can be confounded. 

Treatment. — The course of the disease is almost in- 
evitably toward a fatal termination, and little more can 
be done than to keep the little body as warm as possible, 
to rub in oil, and to administer concentrated nourishment 
and stimulants. Money 1 reported a case in 1889 that 
was cured in six weeks by mercurial inunctions. There 
was no history of syphilis in the case. 

Scleroderma. — Synonyms: Sclerema seu Sclerom adul- 
torum; Scleriasis; Dermato-sclerosis; Chorionitis; Scler- 
ostenosis; (Fr.) Sclereme des adultes, Sclerodermic; 
(Ger.) Haustsclereme; Hide-bound disease. 

A subacute or chronic disease, characterized by hard- 
ness and rigidity of the skin. 

Symptoms. — The name of this disease indicates the 
most peculiar feature of it — that is, hardness of the skin. 
It may come on without apparent cause, the patient first 
noticing the stiffness of the skin; or it may follow expos- 
ure to dampness and cold, and be preceded by pains of 
rheumatic nature. It may begin in any part of the skin, 
but has a preference for the upper half of the body. It 
is usually symmetrical, though it may be more pronounced 
on one side than on the other. Having begun, it spreads, 
it may be very slowly, or it may be so rapidly as soon to 
involve large areas of the body. It often runs a capricious 
course, growing better and worse, and leaving sound areas 
in the midst of the diseased parts. There may be one 
patch or a number of patches, and the patches assume 
many shapes, though most commonly they are elongated, 
running lengthwise of the limb. 

There are two varieties of the disease: 1. The infiltrat- 
ing form. In this there is a good deal of infiltration of 
the skin, which is hard, cannot be pinched up, does not 
pit on pressure, and is attached to the deeper structures. 
The appearance given to the affected part is cadaveric. 

1 Lancet, 1889, i, 526. 



602 DISEASES OF THE SKIN 

In some cases there may be hard oedema. The affected 
part is usually on the level of the surrounding parts, 
though it may be slightly raised. The infiltration merges 
gradually into the neighboring parts, its border being 
ill defined and more readily felt than seen. The natural 
folds of the skin are obliterated, erythema may be present 
at first, and telangiectases are frequently observed upon 
the surface. Not infrequently the patch has a lilac border. 
The color of the skin is paler than that of the normal 
integument, and in some places it may be that of ivory. 
Some scaling may be present, or pigmentation of a mot- 
tled or diffused character may give the patch a fawn or 
black color. Owing to the stiffness of the skin the move- 
ment of the joints is interfered with, a state of pseudo- 
ankylosis being established. If the face is affected, it 
loses its expression, and the features become immobile. 
The eyelids may escape for some time; but if the disease 
passes on to the atrophic stage, soon to be mentioned, the 
eyes become wide open and cannot be closed. If the 
chest is much affected, respiration is interfered with. 
The temperature of the skin is usually lowered one or 
two degrees. It may be normal, or somewhat elevated. 
Senisibility may be increased, normal, or decreased. 
Pruritus is at times annoying. The secretions of the skin 
are lessened with the increase of the disease. The disease 
may invade all the mucous membranes. When it affects 
the tongue chewing, swallowing, or speaking may be 
interfered with. 

2. The atrophic form may succeed the infiltrating form 
after months or years. Crocker thinks that it is prob- 
able that atrophy follows the edematous infiltration only. 
When atrophy begins it is progressive, and the skin be- 
comes dry, wrinkled, parchment-like. It is most often 
the upper part of the body that is affected — the face and 
arms. Continuous contraction of the skin produces an 
atrophy of the muscles under it, so that finally nothing 
remains of the original structures but the skin and bones, 
and the joints are ankylosed. The face being affected, 




Morphea. 

From Tenneson's Precis Iconographiques des Maladies de la Peau. 



MORPHEA 603 

we will find a corpse-like expression, wide-open eyes with 
ulcerated corneas, shrunken gums with loosened and fall- 
ing teeth. The limbs being affected, slight injuries will 
produce ulcerations over bony prominences, and the 
limbs will be semiflexed. The sclerodactylia of Ball is 
scleroderma of the atrophic variety, affecting the hand 
and causing marked atrophy, loosening the joints, and 
distorting the hands, "so that the third and fourth 
fingers are curled up into the hand, the first and second 
are bent at the first phalangeal joint, while the thumb 
phalanges are overdistended" (Crocker). 

The general health remains unaffected in both forms, 
often for years; but should the disease be very pro- 
nounced, at last a marasmic condition develops and death 
occurs. Apart from the pruritus and feeling of stiffness, 
we may have no subjective sensation, excepting that pain 
on pressure is exquisite. At times burning is complained 
of. The disease, when of the infiltrated variety, tends 
to a slow and interrupted course toward recovery. In the 
atrophic variety recovery may take place. Of course, 
the atrophied skin will never regain its natural texture, 
but the disease may cease to spread and increase. At 
best its subject is but a sorry specimen. 

Children may have scleroderma, the youngest reported 
case being thirteen months. In them the disease is said 
to run a more rapid course, both in development and 
recovery, than it does in the adult. Vidal 1 describes a 
form of scleroderma following a lesion of the skin, such 
as an eczema, which gives rise to a lymphangitis, and is 
usually met with on the leg. 

Morphea, Keloid of Addison, is the circumscribed 
form of scleroderma. It occurs either as circumscribed, 
variously sized, oval or irregularly shaped patches, or in 
the form of bands, the former being the more common. 
It begins as a congested, red, rosy, or lilac macule, which 
enlarges, pales in the centre, becomes hardened, and 

1 Gaz. des. Hop., 1878, li, 939. 



604 DISEASES OF THE SKIN 

assumes the form of a characteristic patch of the disease. 
This patch looks like a piece of old ivory or of lard set 
in the skin, being of a yellowish-white color. The color 
may be pinkish, yellow, brown, or even black. The 
skin over the patch is usually smooth and easily pinched 
up. It may be wrinkled, or eroded in the centre. It 
may be level with the surface of the skin, or raised above 
it, or sunken below it. Around it is a lilac border due 
to dilated vessels. When the patch is pinched between 
the fingers it feels firm, like leather. There may be but 
a single patch or a number of patches. As a rule the 
disease is unilateral. After a varying length of time it 
may disappear spontaneously, although it may remain 
for a number of years. There are usually no subjective 
symptoms, and the disease remains unchanged until it 
disappears. In some cases it enlarges by new patches 
developing at the periphery of the old one and uniting 
with it. Exceptionally there may be some itching or 
pain, and ulceration may occur. Sensation is generally 
preserved. The band form is usually single, and may 
form a depressed sulcus or a raised ridge, looking much 
like a cicatrix. In addition to the bands there may be 
atrophic spots. 

The most common locations of morphea are anywhere 
on the trunk, but specially on the breasts; on the head 
and face in the parts supplied by the fifth nerve; and on 
the limbs. It is not infrequently associated with other 
nervous phenomena, and may occur along the course of 
a nerve, like zoster. Nettleship 1 has reported a case in 
the region of the first and second divisions of the fifth 
nerve with paralysis of the intra-ocular branches of the 
third nerve, which in time had associated with it hemi- 
atrophy of the whole of the left side of the head. There 
is no disturbance of the general health. The secretion 
of sweat over the patches may be normal, lessened, or 
absent. When the disease disappears it may leave no 

1 Trans. Clin. Soc. Lond., 1882-3, xvi, 199. 



MORPHEA 605 

trace of itself; or it may be followed by pigmentation, 
or even permanent atrophy, not only of the skin, but 
also of the muscles. A form of leprosy has been wrongly 
named morphea. 

Etiology. — Women are far more often the victims of 
scleroderma than are men — three to one. It is most 
common in young and middle-aged adults. Apart from 
this, we are in uncertainty as to the true cause, though 
rheumatism, gout, exposure to cold and heat, bad hygiene 
and poor food, changes in the thyroid, and neurotic 
influences have each been found in apparent causative 
relation to the disease. At the foundation of the trouble 
there is supposed to be some defect in the nervous system, 
not improbably in the vasomotor centres. "Most of the 
symptoms are referable to obstruction, on the one hand, 
to the arterial blood supply, and on the other, to the 
venous and lymph flow" (Crocker). 

Pathology. — There is atrophy of the fat in the derma 
and subcutaneous tissue, with condensation and increase 
of the connective tissue. The bloodvessel walls are 
thickened, and their lumina narrowed by the pressure 
of surrounding masses of cells of unknown origin. These 
cells are plentiful also in the neighborhood of the glands, 
which, in the later stages may be atrophied. The pa- 
pillae are hypertrophied only in those cases which show a 
papillomatous tendency. 

Diagnosis. — There is no other disease of the skin 
with which diffused scleroderma could well be confounded, 
excepting sclerma or oedema neonatorum, or cancer en 
cuirasse. The age at which the first two occur — namely, 
the first few days of life — would throw them out. Can- 
cer en cuirasse is more rapidly fatal in its course, is at 
first or soon marked by subcutaneous nodules that tend 
to break down and ulcerate, and is accompanied by 
lancinating pain. 

Keloid differs from morphea in having claw-like pro- 
cesses, in being more vascular and harder, and in want- 
ing the old-ivory color and lilac border. Leprosy has 



606 DISEASES OF THE SKIN 

anesthetic patches, which morphea has not. Vitiligo is 
a pigment change only, and has no other symptoms. 

Treatment. — It is doubtful if treatment is ever 
directly of avail. At best it is unsatisfactory. A gen- 
eral symptomatic treatment with tonics, good diet, and 
maintenance of the body heat is indicated. Stelwagon 
recommends the administration of arsenic, sodium sali- 
cylate, and cod-liver oil. Thyroid extract should be tried. 
Galvanism, inunctions of the skin with oil, and massage 
may be tried. West 1 has reported amelioration in one 
case by the external use of chaulmoogra and olive oils. 
Stelwagon has had good results in morphea from oil of 
turpentine 1 to 2 parts in 6 of oil of sweet almonds, 
or with 1 part of beta-naphtol, 2 parts oil of sweet 
almonds, and 10 parts of lanolin. Hyde has obtained 
benefit by the use of common salt, either moistening it 
with warm water until it is partially dissolved, and then 
rubbing it briskly over the entire surface of the body 
excepting the face, and then washing it off with water of 
decreasing temperature until cold water is used; or a 
warm tub or sponge bath is taken containing J of a pound 
of salt to the gallon. Mercurial or thiosinamin plaster 
may be tried. We have seen one case improved by inunc- 
tions of vaselin containing 10 per cent, of salicylic acid. 
Electrolysis has proved helpful in small patches of mor- 
phea. The high-frequency current is sometimes useful. 

Prognosis. — While recovery may take place, it is 
uncertain as to its occurrence. Death may result in the 
diffused form. In children the prognosis is more favorable. 

Scrofuloderma. — Modern pathology has led, or is lead- 
ing us to use the term tubercular as synonymous with 
scrofula, and a number of dermatoses that were for many 
years regarded as scrofulodermas have been proven to be 
due to the bacillus tuberculosis. The most brilliant 
example of this is lupus vulgaris. Many of the scrofulides 
of the French have been shown by more careful obser- 

i Trans. Path. Soc. London, 1883, xvi, 252. 



SCROFULODERMA 607 

ration to belong to various other well-recognized forms 
of skin disease. The marks of a scrofulous affection are, 
according to Bazin: (1) the involvement of the deeper 
layers of the skin; (2) the sharply circumscribed character 
of the lesions; (3) the absence of pain; (4) hypertrophy 
followed by atrophy of the affected parts ; (5) the reddish, 
violaceous, or livid color of the lesions; and (6) indelible 
cicatrices left by the same. 

In the present condition of our knowledge of the sub- 
ject, and in a book of this sort, it is impossible to do more 
than to place here a few affections of the skin that do not 
fit in under other well-established diseases, while premis- 
ing our remarks by saying that they are either really 
instances of cutaneous tuberculosis or due to its toxins 
or will eventually be taken out of their present position 
as scrofulodermas. In all of them we have, at the same 
time, that general make-up of the individual that long has 
been recognized as scrofulous. The patients are mostly 
young subjects, flabby of flesh, with pasty or doughy com- 
plexions or transparent skins, thick upper lips, perhaps 
with clubbed fingers, a marked tendency to chronic 
catarrhal inflammations of all the mucous membranes, 
chains of enlarged glands in the neck, and perhaps with 
some old or present bone lesions. They are usually dull 
and apathetic, but may be unusually intellectual, and are 
prone to die with tubercular lung diseases. 

The most common scrofuloderm is that resulting from 
a suppurating caseous gland, usually of the neck — the 
scrofulous tuberculous ulcer. The gland, before it breaks 
down, implicates the skin over it, and it becomes of 
violaceous or livid color, attached to the underlying 
parts. By and by the skin gives way at one or several 
points; the sanious, unhealthy pus escapes through the 
openings; these enlarge, coalesce with others, and so form 
the characteristic ulcer. This has undermined edges; 
is of irregular shape; its base is covered with flabby 
granulations; it discharges a thin, sanious pus; shows 
little tendency to crusting; is almost painless, and heals 



608 DISEASES OF THE SKIN 

very slowly, leaving a puckered, disfiguring scar that is 
often bridled, with bands of connective tissue running 
across the site of the ulcer, under which a wooden tooth- 
pick, or the like, can be passed. Only one gland may be 
affected, or there may be a number of them that enlarge 
and break down. This same form of ulcer may originate 
from what is called a scrofulous gumma, a subcutaneous 
nodule independent of the glands, that slowly enlarges 
to a soft tumor, breaks down, and ulcerates. These 
tumors frequently occur on the limbs, and the bones may 
be involved in the destructive processes set up. 

While this is the most common scrofuloderm, we occa- 
sionally meet with two forms described by Duhring — the 
large and the small pustular scrofuloderm. The former has 
"large, rounded, ovalish, or irregularly shaped, yellow- 
ish, flat pustules, with a deep-red or violaceous areola/' 
This begins to crust in the centre, and the crust is usually 
flat and scanty, brownish and adherent. Underneath it is 
an ulcer with the characters and course of those just 
described. There may be one, two, or more lesions. 
The small pustular scrofuloderm " consists in the forma- 
tion of pinhead- and small split-pea-sized, disseminated, 
yellowish, flat pustules, with usually a raised, violaceous 
areola." These crust over with depressed yellowish or 
gray adherent crusts, which when removed, or when 
they fall off, leave depressed, punched-out scars resem- 
bling variola. Their course is very chronic and painless. 
They occur upon the face and extremities of strumous 
individuals. This form is probably the same as folliclis 
of Barthelemy. 

Etiology. — The causes of these scrofulodermas are 
those of the strumous state plus infection by the tubercle 
bacillus, and need not be gone into here. They are most 
commonly met with in early life. 

Diagnosis. — The scrofulous ulcer differs from that of 
lupus vulgaris in an entire absence of the characteristic 
lupous tubercles, and in its history of beginning in a 
caseous gland. Moreover, in lupus we do not have, as a 



SEBORRHEA 609 

rule, the pronounced strumous condition that we have in 
the scrofuloderm. The pustular scrofuloderms sometimes 
resemble syphilis, but there is an absence of other signs of 
syphilis, and the presence of the strumous state. More- 
over, the pustular syphilide is generally far more dissemi- 
nated than is the scrofuloderm; its course is far more 
acute; it yields more readily to treatment, and leaves a 
smoother, less disfiguring scar. • 

Treatment. — The treatment of the ulcers, as well as 
the softening glands, is upon surgical principles. The 
regulation of the diet and hygiene of the patient, and the 
administration of cod-liver oil, iron, the compound syrup 
of the hypophosphites, or other tonic, is the most essential 
part of the medicinal treatment. Tuberculin injections 
should be tried. Locally, to the pustular scrofuloderms 
we may apply iodoform ointment, aristol, or other anti- 
septic powder, or mercurial ointments or lotions. Crocker 
speaks well of chaulmoogra oil emulsion in the dose of 
10 to 30 minims, combined with its external use as an 
ointment in the strength of 1 part to 3. 

Seborrhea. — Synonyms: Stearrhea, Steatorrhea, Sebor- 
rhagia, Fluxus sebaceus, Acne sebacea, Pityriasis, Ich- 
thyosis sebacea, Tinea amiantacea seu asbestina, Lichen 
circinatus; (Fr.) Acne sebacee. Acne fluente; (Ger.) 
Schmeerfluss; Gneis; (Ital.) Seborrea. 

A functional disorder of the sebaceous glands, in which 
there is a hypersecretion of sebaceous matter, which may 
be of too fluid or too solid consistence, ' and forms either 
an oily coating or greasy crusts on the skin. 

Symptoms. — Normally the sebaceous glands secrete 
only sufficient oil to keep the skin soft and supple. This 
normal oil is not visible to the naked eye. Under certain 
imperfectly understood conditions the glands secrete a too 
fluid and abundant oil that is readily seen as an oleagi- 
nous coating of the skin. This form of seborrhea is called 
seborrhea oleosa, and by many authorities is now declared 
to be the only form of seborrhea. By others, it is thought 
39 



610 DISEASES OF THE SKIN 

that under certain other equally imperfectly understood 
conditions the secretion of these glands is not only too 
abundant, but also too consistent. Then the sebaceous 
matter cakes upon the skin in the form of more or less 
thick plates or masses, and to this condition the name of 
seborrhea sicca is given. The latter form is regarded by 
those who believe that there is but one form of seborrhea 
as pityriasis steatodes. In deference to the older teach- 
ings, both forms will be described. 

The most common locations of seborrhea are, naturally, 
those regions where the sebaceous glands are the largest 
or most numerous, namely, the scalp, the chest, the 
interscapular region, and the face. 

Seborrhea oleosa, while it may occupy any or all of 
these regions, is usually submitted to us for treatment 
when it occurs upon the face and scalp. Upon the face 
it is seen most often on the nose, where it forms a greasy 
coating. At times this is so slight as to be felt rather than 
seen, imparting a slippery sensation to the finger. At 
other times it is so abundant that it can be seen at a 
distance as drops or beads of oil, and when it is removed 
with a cloth or blotting-paper it leaves an oily stain upon 
it. When it is wiped off it at once reforms. As the greasy 
patch catches the dust, the face is apt to look dirty. At 
times the skin of the nose may be hyperemic. The fore- 
head is, likewise, a not uncommon site for this form of 
seborrhea. Upon the nose it may occur as the only dis- 
ease of the skin. Upon the forehead and nose it is not 
an unusual accompaniment of acne. Acne and comedones 
may complicate the disease in any location. 

The scalp may be affected primarily or secondarily to 
the forehead. It and the hair appear oily or greasy, 
the degree varying a good deal. Inspection of the scalp 
shows marked dilatation of the pilosebaceous glands. If 
it is pinched up between the fingers a number of minute, 
white, vermicelli-like masses will protrude from the 
follicles. These are the seborrhoic filaments of the French 
writers, and are regarded by them as pathognomonic 



SEBORRHEA 611 

of the disease. They may be waxy in consistence (sebor- 
rhea sicca), or as soft as butter. The whole scalp is 
involved. Scaling is absent as a rule. It is apt to cause 
alopecia. 

Seborrhea sicca occurs with much greater frequency 
than does the oily form of the disease. We are called 
upon to remove it from all the regions already mentioned 
as the locations for the manifestations of seborrhea. It 
most usually appears in the form of yellowish or grayish 
fatty plates or masses, which when taken and rubbed be- 
tween the fingers impart a greasy feel. Upon the scalp 
it constitutes one form of dandruff. Here it may be gen- 
eral, involving the whole scalp; or it may locate itself in 
certain places in a more pronounced way than in others; 
or it may take the form of rings. It not infrequently 
occurs as a band on the forehead following the edge of 
the hair. The hair is dry, and after a time, the sebor- 
rhea continuing, it begins to fall, and at last baldness is 
established. 

In this form of seborrhea the hairy regions are espe- 
cially affected, and we find it in the eyebrows, bearded 
portions of the face, and the hairy portions of the chest. 
The axillae and pubes are rarely affected. In all these 
places it presents similar appearances — yellowish or gray- 
ish fatty plates. Upon the chest it is not uncommon to 
see the fatty matter in little heaps, piled up, as it were, 
about the mouths of the hair follicles. Close observation 
will show that the follicle mouths are wider open than 
they should be. As in the oily form, the skin feels greasy, 
and acne and comedones may be present. The inter- 
scapular region is frequently affected, and both here and 
on the chest the disease often takes the form of round 
or irregularly shaped patches which look as if they were 
covered with a brownish-yellow varnish. This is the 
seborrhea corporis of Duhring and the lichen circinatus 
of the older English authors. 

Aside from the appearance of the fatty crusts and a 
slight amount of itching when the patient is warm, this 



612 DISEASES OF THE SKIN 

form gives rise to no symptoms. When the crusts are 
removed the underlying skin is of normal appearance, 
It may be slightly paler than it should be, but it is never 
moist. If the patient happens to be bald, he does not 
find the yellowish fatty crusts upon his bald head desir- 
able. But the most serious aspect of the case is that if 
the disease is not cured it is very sure to cause the hair 
to fall, especially if the patient is at all predisposed to 
baldness. 

Besides the regions already mentioned as the usual 
locations of seborrhea, we meet with the disease also 
upon the ears (in the tragus and behind the ears) and in 
the anal fold The scalp is, however, by far the most 
frequent location of the disease, and here it may exist 
alone for years. Whenever it exists elsewhere it is sure 
to be found at the same time upon the head. 

In infants the disease is very common, taking the form 
of thick crusts upon the scalp that are often of a dirty- 
gray color. These give the careful mother a good deal of 
annoyance, she being in great dread lest some one should 
think that she is not careful to keep the precious baby 
clean. This form of the disease is usually the remains 
of the vernix caseosa. 

Etiology.— The usual etiological factors of seborrhea, 
as given in the text-books, are debility, chlorosis, 
constipation, and a number of other things, indicating 
that the condition of the patient is below par. It is 
quite common to see seborrhea appear on the scalp 
after some constitutional illness. The disease affects 
all classes and conditions of men, all ages, but with the 
greatest frequency between the ages of fifteen and thirty, 
and both sexes. There is no doubt that heredity is the 
cause of many cases of seborrhea, as very often the 
greasy skin can be traced back through many generations. 

There are many things that seem to indicate a conta- 
gious element in the etiology of seborrhea sicca. Cases 
have been reported in which a husband or wife has 
contracted dandruff after marriage, he or she having 



SEBORRHEA 613 

been, before, free from the same. The experiments of 
Lassar and Bishop point in the same direction. They 
took the scales from the head of a student who was losing 
his hair, and, having made a pomade of them with vaselin, 
rubbed the same into the back of a guinea-pig, and the 
pig became bald. Up to a few years ago we accepted 
without question the theory that seborrhea is a functional 
disease of the sebaceous glands. This is now doubted by 
some authorities. Unna teaches that the process is 
inflammatory from the start, and that the oil that fills 
the epithelial scales comes not from the sebaceous glands, 
but from the sweat glands. What we have called sebor- 
rhea sicca he would have us call, for the present at least, 
seborrheal eczema. (See Dermatitis seborrhoica.) He 
regards it also as parasitic. In support of his thesis he 
presents us with microscopic studies and certain argu- 
ments. His work has been reviewed by other competent 
pathologists, and his observations have been substanti- 
ated by other findings. His proposition that the sebaceous 
glands are not responsible for seborrhea has not been 
accepted generally. What is called seborrhea oleosa, 
Unna believes to be nothing more than hyperidrosis, 
to which he gives the name of hyperidrosis oleosa. This 
view he must take of necessity, on account of his theory 
of the office of the sweat glands. 

It is affirmed that seborrhea is due to a microorganism. 
Sabouraud gives strong evidence that it is due to a 
microbacillus that is identical with the acne bacillus of 
Unna. 

Diagnosis. — There is no difficulty in the diagnosis of 
seborrhea oleosa, as there is no other disease which 
gives the oily, greasy appearance to the skin. The 
diagnosis of seborrhea sicca is usually easy. It is to be 
recognized by the presence of fatty grayish or yellowish 
plates or crusts, seated either upon a normal or slightly 
reddened skin. These crusts or plates differ from those 
met with in eczema in being more readily removed, and 
imparting to the finger a greasy feel. Moreover, the 



614 DISEASES OF THE SKIN 

crusts of eczema are of a more solid consistence, being 
formed by the dry ng of an almost mucilaginous dis- 
charge upon the skin. When eczema occurs upon the 
head the exudation glues the hairs together. In sebor- 
rhea the hairs are not glued together, but are dry and 
powdery. In eczema there is more or less itching at all 
times, while in seborrhea the itching comes on most gener- 
ally when the head is hot, as from artificial lights, sweat- 
ing, and the like. In eczema there is moisture or a strong 
tendency thereto. In seborrhea moisture is never seen. 
Seborrheal dermatitis always presents redness of the skin, 
and at times passes over into an eczematous condition. 

Psoriasis is another disease with which seborrhea sicca 
is apt to be confounded, as it, too, occurs in the form of 
scales and crusts upon the scalp. If a case presents 
itself with these conditions upon the head alone, we 
probably have to do with a case of seborrhea, as psoriasis 
rarely exists upon that region alone. Seborrhea usually 
occurs diffusely, while psoriasis occurs in the form of 
circumscribed patches. The crusts of seborrhea are 
yellowish or grayish, while those of psoriasis are of a 
silvery hue. In some cases, however, seborrhea will 
occur in circumscribed patches, and the crusts of psoriasis 
may be of a grayish hue. 

When seborrhea sicca occurs upon the chest and back 
in the form of rings with scaly centres, we have before us 
a more difficult problem in diagnosis. Now we must 
decide whether we have to do with a seborrhea, a ring- 
worm, or a pityriasis rosea. The resemblance to ring- 
worm is often very striking, but ringworm does not, as a 
rule, occur in so diffuse a manner. If, at the same time 
with the lesion on the chest, we find other lesions on the 
back between the shoulder-blades, we may be quite sure 
that the case is one of seborrhea. Happily in any doubt- 
ful case of ringworm, we will surely find the trichophyton. 
Upon examining the scalp, if the disease be seborrhea, 
we will surely find plain evidence of it there. There 
should be no difficulty in recognizing the presence of a 



SEBORRHEA 615 

ringworm on the scalp. In the differential diagnosis from 
pityriasis rosea we are deprived of the kindly aid of the 
microscope. Here, too, the occurrence of seborrhea on 
the scalp will aid us in our decision. Moreover, pityriasis 
rosea is generally more diffused over the trunk than is 
seborrhea, and occurs also on the arms and abdomen. 
By close inspection we may trace the development of the 
disease from its beginning as a small red spot through its 
successive growth into the typical oval to annular patch 
with its withered parchment or chamois-leather-like look- 
ing centre. It is scaly, never crusted. In some cases, 
however, the diagnosis will remain somewhat doubtful. 
Treatment. — Any deterioration in the patient's gen- 
eral condition must be combated by appropriate means. 
Sabouraud advises the administration of arsenic and 
phosphoric acid. It is possible that reduction in the use 
of fat-producing food may be useful in the oily form. 
In the local treatment of the dry form ointments do best, 
while in the oily forms lotions are preferable. One of the 
best drugs in the less oily form is sulphur. After the 
removal of the crusts by washing with soap and water, 
the sulphur is to be applied in the strength of a dram 
of the precipitated sulphur to an ounce of rose ointment 
It should be well rubbed into the scalp, and the appli- 
cation repeated every night for one week. It must be 
remembered that the remedy is to be applied to the 
scalp and not to the hair, and that it is necessary to use 
only a very little of the ointment. After one week's 
use of the sulphur the head is to be washed with soap and 
water, and the salve, immediately reapplied. During 
the second week it will be sufficient to make the applica- 
tion every other night. Thus the treatment is to be con- 
tinued, the number of applications being reduced until 
they are made but once a week. By this time the disease 
will usually be cured. The patient is to be cautioned 
that relapses are likely to occur, and therefore it will 
be best for him to keep a supply of his salve on hand, so 
as to attack the trouble as soon as it shows itself. 



616 DISEASES OF THE SKIN 

The ointment recommended by Dr. E. B. Bronson 
is a very elegant as well as efficient substitute for the 
sulphur. It is: 

1$ — Hydrarg. ammon., gr. xx-xl 1.33-2.66; 

Hydrarg. chlor. mitis, gr. xl-lxxx 2.66-5.33J 

Vaselini, ad §j ad 32 M. 

This is to be used in the same manner as the sulphur 
ointment. 

While one or the other of these will bring the case to 
a happy issue, it is well to have a variety of means at 
command. H. R. Crocker 1 commends: 



-Ac. acetici, 


5ss-j 


15-30 


Resorcin., _ 


3i 


4 


Aq. cologniensis 


5ij 


60 


Glycerini, 


3j 


4 


Aqua? rosse, 


ad 5 vii j 


ad 240 



M. 

Some other remedies are salicylic acid in castor oil, 
3 per cent, strength; resorcin in oil, diluted alcohol, or 
vaselin in 3 to 10 per cent, strength; or a solution of 
hydrate of chloral, a dram to the ounce. A favorite 
formula is : , 

06 



1$ — Hydrarg. bichlor., 


gr. j 






Resorcin. seu, 


3J 




4 


Euresol, 








01. ricini, 


gtt. XV 




1 


Alcohol, 


ad giv 


ad 


120 



M. 

This will cause an exfoliation of the scalp in some cases, 
but this does no harm. Resorcin should never be pre- 
scribed for those whose hair is white, gray, or blond, as 
it stains the hair a greenish shade. 

For a soap, both for cleansing and stimulation, the 
tincture of green soap or tar soap may be used. If the 
scalp is peculiarly irritable, then it is best to use a 
milder soap, such as glycerin soap. 

The treatment of seborrhea of the body and face is 
upon the same lines as that of the scalp, only on the 
body we can use an ointment instead of an oil. 

1 Clin. Jour., London, 1897, x, 81. 



Sporotrichosis. (Arndt.) 



SPOROTRICHOSIS HYPODERMICA 617 

For the seborrhea of infants usually all that is re- 
quired is to keep the scalp well oiled with olive oil. If 
this does not cure, then a mild sulphur ointment with 
vaselin may be used. 

For seborrhea oleosa of the face, dabbing ether on the 
part will most promptly remove the greasy look. Washing 
with soap and water will act as a stimulant. Powdering 
with sulphur and starch; or using a 3 per cent, solution 
of resorcin in alcohol and water, will tend to cure, but 
the disease is seldom eradicated, and is always more 
difficult to treat than the dry form. 

Prognosis. — Seborrhea oleosa is often recovered from 
when the patient is in good general condition. Sebor- 
rhea sicca is usually readily relieved, but is very sure to 
return, so that the patient must keep by him for further 
use any remedy he has found efficacious. 

Seborrhea Congestiva. — See Lupus erythematosus. 
Shingles. — See Zoster. 

Siderosis. — A defacement of the skin due to the en- 
trance into it of small particles of iron or steel, producing 
blue-black marks. It is seen in iron-workers. 

Spider Cancer. — See Telangiectasis. 

Sporotrichosis Hypodermica. — According to De Beuer- 
mann and Gougerot 1 this disease is due to the invasion 
of the skin by several kinds of Sporotrichium, a vege- 
table fungus. 

Symptoms. — The invasion takes place insidiously. 
Once the disease begins it is progressive. It usually 
causes no disturbance of the general health, but in some 
acutely developing cases there may be fever, loss of 
flesh, and other constitutional symptoms. It occurs in 
three forms. 

1st Form. Three or four weeks after invasion there 
is an eruption of subcutaneous nodules over the whole 

1 Annal. derm, et syph., 1906, vii, 837. 



618 DISEASES OF THE SKIN 

body. Each nodule attains its full maturity and be- 
comes an abscess in from four to six weeks. They begin 
as small, subcutaneous, hard, elastic, movable, painless 
nodules, 5 to 6 mm. in diameter, which are but slightly 
elevated. The skin at this stage is unchanged. They 
slowly enlarge to the diameter of 20 or 30 mm., become 
more elevated, and the skin over them becomes rosy, 
violaceous, or brown in color. In about four weeks' 
time softening of the nodes occurs. The nodes go on to 
form abscesses which do not tend to open of themselves. 
The contents of these abscesses is viscous or gummous, 
at first translucent though streaked with pus. Later 
it is purulent, opaque, and thick, and cultures show 
sporotrichium Beuermann. If an abscess is opened, 
the incision remains open, and a little thick serum wells 
out which may or may not be purulent. The incision 
gapes and transforms itself into a round ulcer, secreting 
a sero-pus, which forms a thick crust. Untreated the 
disease continues to spread in the same manner. 

2d Form. This is like the first, but its abscesses are 
larger, they heal easily, contain gray-whitish pus, and in 
their cultures is found another species of sporotrichium 
called S. Dori. This is a fungus midway between a 
streptothrix and a trichophyton. 

3d Form. In this, in from one to three months after 
a traumatism, a small cold abscess develops at the point 
of inoculation which leaves a persistent ulceration last- 
ing many months. Some days or weeks after the initial 
lesion a hard nodule appears above it in the course of 
the lymphatic trunk, and so the disease spreads up the 
limb. The nodes undergo softening and ulcerate spon- 
taneously. The lymphatic trunks between the nodules 
can be felt like whip cords, but the skin is sound and the 
health unaffected. This form is due to the S. Schenkii, 
which differs from the other two. 

Cases of mixed types are occasionally encountered. 

Etiology. — The disease is caused by the invasion of 
the skin by the sporotrichium, of which there are several 



SPOROTRICHOSIS HYPODERMICA 619 

varieties. The organism consists of branching, septate, 
coarse mycelia, from which ovoid bodies develop by 
budding. Infection takes place usually from decaying 
vegetable matter, and the disease is met with principally 
in farmers. 

Fig. 90 




The organism from Case 1, a branching, septate coarse mycelium, 
from which ovoid bodies (spores) develop by budding, either from 
lateral or terminal filaments, or from the sides of the threads. (Sutton: 
Jour. Amer. Med. Assoc, 1911, lvi, 1309. 



Diagnosis. — Syphilis is diagnosed from sporotrichosis 
by having fewer gummatous lesions which undergo a 
slower evolution, and form smaller abscesses. They open 
of themselves, and the ulcers that form have more in- 
filtrated dark red borders, their floor is more uneven, and 
their crusts are green. Their cultures do not show sporo- 
trichia. Mercury cures them, and has no influence on 
sporotrichosis. Blastomycosis affects the health more 
profoundly, its evolution when acute, is attended by 
fever, its abscesses are painful, and it has other skin 



620 DISEASES OF THE SKIN 

lesions. The organism found in the cultures is not 
the same. 

Treatment. — All forms yield readily to iodide of 
potassium, 30 to 60 grains a day. The gummas should 
be opened, and the ulcerations treated with compresses 
of a solution of iodine 1, potassium iodide 10, water 
500. 

Sweating, Excessive.— See Hyperidrosis. 

Sycosis. — Synonyms: Sycosis non parasitica; Sycosis 
menti; Sycosis barbae; Mentagra; Acne mentagra; Fol- 
liculitis barbae; Folliculitis pilorum; Herpes pustulosus 
mentagra; Lichen menti; Acne sycosis; (Fr.) Sycosis 
non parasitaire; Dartre pustuleuse mentagre; Adeno- 
trichie; (Ger.) Bartfinne, Bartflechte; Fikosis; (Eng.) 
Barber's itch. 

An acute or chronic follicular and perifollicular inflam- 
mation of the long hairs, chiefly affecting the bearded 
portions of the face; characterized by an eruption of 
papules, pustules, and nodules perforated by hairs; by 
the formation of infiltrated patches; and by a greater or 
lesser amount of crusting. Sometimes the disease is so 
intense that abscesses form. 

Symptoms. — The disease begins by the formation of a 
number of red inflammatory papules and nodules which 
are more or less conical, usually raised above the surface 
of the skin, and always perforated by hairs. Their 
appearance is preceded and accompanied by disagreeable 
local sensations, such as pricking, burning, and smarting, 
and at times by a feeling of tension in the part on account 
of swelling of the skin. In acute cases there is con- 
siderable redness of the skin between the papules, and 
the inflammation may be so intense as to give rise to 
enlargement of the neighboring lymphatic glands. The 
papules and nodules vary in size from that of a millet- 
seed to that of a pea, and are isolated or grouped, not 
every hair follicle in a diseased part being affected by 
the perifollicular inflammation. Only in very severe 



SYCOSIS 



621 



outbreaks or in acute exacerbations do the papules and 
nodules tend to run together and form infiltrated 
patches. 

The papules and nodules soon change into pustules, 
which are likewise always pierced by hairs. These 



Fig. 91 




Sycosis vulgaris of moderate development. (Stelwagon.) 



pustules, conical in shape, and perforated by hairs, are 
pathognomonic of the disease. In old cases they are 
met with in the infiltrated patches arising apparently 
without the preceding appearance of papules and nod- 
ules. The pustules show no tendency to rupture, but the 



622 DISEASES OF THE SKIN 

pus accumulates below, swells up alongside of the hair, 
appears upon the surface of the skin, and dries into thin 
crusts. The amount of crusting is never very great, 
far less than in eczema of the beard, mainly limited to 
the affected follicles, and is most appreciable when the 
beard is growing. If the inflammation is very intense, 
we may meet with small cutaneous abscesses here and 
there instead of pustules. According to A. R. Robinson, 
the amount of pus-production varies with the individual 
attacked, being more rapid and abundant in the robust 
than in the scrofulous; in acute than in chronic cases. 

The hairs, if of any length, are early affected in appear- 
ance, becoming lustreless. They are at first firmly 
seated in their follicles, and when pulled upon give rise 
to pain, and if extracted their root sheaths will appear 
as clear glassy cylinders. Later, as pus forms more 
abundantly in the perifollicular tissues, and the follicles 
themselves are involved in the process, the hair becomes 
loosened and easily extracted, when its root sheath will be 
found swollen with pus. If the pus production is exces- 
sive, the hairs will fall of themselves or upon the slightest 
traction. When this occurs the hair papillae may be so 
damaged that no new hairs will form. In chronic cases 
the beard is markedly thinned, though permanent loss of 
hair is the exception. 

The disease may attack any part of the bearded face, 
and may be met with in other hairy regions, as the neck, 
the eyebrows, scalp, axilla, and pubes. Occurring else- 
where than on the face the disease is called folliculitis, 
and not sycosis. But the beard is by far most often the 
site of the disease, the other situations being affected in 
the order in which they are named. Occurring in the 
beard, it may be limited to a single region and show no 
tendency to spread. Thus it is met with very frequently 
upon the upper lip alone, or at times upon the cheeks 
alone. When it affects the upper lip alone it is always 
preceded by nasal catarrh, and takes the form of a 



SYCOSIS 623 

diffused dermatitis with much thickening of the lip and 
some crusting. It may attack the whole bearded face in 
an acute outbreak, or it may involve it by extension from 
a limited area during a number of successive outbreaks. 
Very often it spares the chin. In chronic cases it is 
usually symmetrical. The course of the disease is chronic 
and made up of a number of acute exacerbations. If 
left to itself, it may produce a good deal of deformity, the 
lesions breaking down, ulcerating, and leaving cicatricial 
tissue and more or less baldness, though this is excep- 
tional. To this the name of ulerythema sycosiforme has 
been given. 

A typical case of sycosis presents the following appear- 
ance: upon a single region, two or more regions, or upon 
the whole bearded portion of the face there will appear 
a number of isolated or grouped papules, nodules, and 
pustules pierced by hairs. The skin about the lesions is 
reddened and swollen, it may be indurated, and there is a 
slight amount of crusting. There is no tendency for the 
disease to spread to non-hairy parts, but very commonly 
the eyebrows will be similary affected, and a blepharitis 
will be present. When the case is watched for a time 
marked exacerbations will arise often without apparent 
cause, last for a few days, and then the disease will sink 
into a subacute condition only to light up again. When 
the disease affects the vibrissas of the nose, by extension 
from the upper lip, the Schneiderian membrane becomes 
swollen and exquisitely sensitive. The patient does not 
complain of itching, but of pain and discomfort. The 
disease tends to run a chronic course, lasting for years. 

Etiology. — The disease is undoubtedly microbic due to 
the invasion of the hair follicles by staphylococcus albus 
et aureus. In the great majority of cases it is the latter. 
It is not very common, perhaps one case in three or 
four hundred. It is doubtless contagious in some cases, 
and frequently transferred by the agency of the barber 
shop. It is seen in men almost exclusively, as we might 



624 DISEASES OF THE SKIN 

expect, as it is the beard that is most often affected 
and attacks them most frequently between the ages of 
twenty-five and fifty. It affects all classes and condi- 
tions. Most of its subjects are in poor general con- 
dition. 

Eczema is often a forerunner of sycosis, the one process 
passing over into the other. A nasal catarrh is the cause 
of the majority of cases occurring on the upper lip. 
Shaving with a dull razor against a stiff beard is said to be 
sometimes an exciting cause, though those who do not 
shave are by no means exempt from the disease. The 
barber shop is a prolific source of contagion. An irritant 
applied to the skin may excite it, such as exposure to 
intense heat, the dust of a workshop, cosmetics, poultic- 
ing and the like. Exposure to inclement weather is 
regarded by Wilson as the principal cause. Given a 
hyperemic or irritable condition of the skin of the face, 
arising from any internal or external cause, the hairs, 
especially if they are coarse, may excite the disease, 
acting as irritants when touched or moved. 

Hebra thinks that some cases may be due to an abnor- 
mality in the growth of new hairs. Wertheim ascribed 
the inflammation to irritation of the hair follicle by hairs, 
whose diameter was, relatively, too large for their follicles. 

Pathology. — The disease is primarily a perifollicu- 
litis, the hair follicles being affected secondarily, and 
after them the sebaceous glands. The hair papillae, as a 
rule, are not destroyed. Tommasoli has described a 
special organism as its cause, which he named bacillus 
sycosiferus fetidus, and has produced the disease in 
rabbits by inoculating them with pure cultures of his 
bacillus. 

Diagnosis. — The distinguishing characteristic of sycosis 
is the presence of pustules pierced by hairs. It may 
be diagnosed from trichophytosis barbae, eczema barbae, 
the small pustular syphiloderm, acne, and lupus. The 
differential diagnosis of sycosis from trichophytosis barbce 
is as follows: 



SYCOSIS 



.25 



Trichophytosis Barbae. 

Begins as a small scaly spot, a su- 
perficial ringworm, and gradu- 
ally involves the deeper parts 
of the hair. 

Has its favorite seat upon the chin 
and the submaxillary region; 
rarely attacks the upper lip. 



The eruption consists of nodules 
which tend to group and are 
studded with a number of hairs. 
The internodular portions of the 
skin often remain unaffected. 



Is a deep inflammatory process so 
soon as the hairs become af- 
fected. 

Hair is diseased primarily, and is 
twisted, split and broken. May 
readily be removed by slight 
traction and without pain. Its 
root is often dry. 

Subjective symptoms slight, may 
be only slight pruritus. 



Patches of ringworm often present 
on other parts of the body, and 
sometimes the disease extends 
upon the neck or face. 

Hairs and scales loaded with the 
trichophyton fungus. 

Is a progressive disease, and when 
cured not liable to relapse. 



Sycosis. 

Begins suddenly with an outbreak 
of papules which soon become 
pustules, each of which at the 
start involves a hair. 

Its favorite seat is the upper lip, 
and sometimes it alone is in- 
volved. Involves the hairy por- 
tions of the face more generally, 
and is often symmetrical. 

The eruption consists of papules 
and pustules, each of which is 
pierced by a single hair, and 
they show no disposition to 
group. The intervening skin is 
generally reddened, and may be 
diffusely infiltrated; and ab- 
scesses may form. 

Is a more superficial inflamma- 
tion. 

Hair diseased secondarily, and 
comes away at first with diffi- 
culty, causing much pain. 
Later is easily removed and its 
root is swollen with pus. 

Subjective symptoms of pricking, 
burning, and tension of the part. 
These are often intense and at- 
tended by swelling of the face. 

Limited in most cases to hairy 
parts of face. No tendency to 
extend on non-hairy parts of 
face or neck. 

The ordinary pus cocci only are 
found. 

The course of the disease made up 
of a number of acute outbreaks. 
Liable to relapse. 



The differential diagnosis from eczema of the beard 
cannot be made with so much certainty, and often we 
must remain for a while in doubt as to the true nature of 
the case. At times sycosis is left by a preceding eczema, 
and we may meet with a case in the transition stage when 
a sure diagnosis would, manifestly, be impossible. A 
typical case of pustular eczema is attended by a far 
greater amount of crusting than is sycosis, and the crust 
is of a more greenish or blackish color. Upon removing 
the crust in eczema a moist and oozing surface will be 
exposed, while in sycosis we will do no more than remove 
the "tops from a number of pustules. In eczema the pus- 
40 



626 DISEASES OF THE SKIN 

tules break down more readily than in sycosis, and they 
are not so accurately located about the hairs. In eczema 
the whole surface of the skin is involved, and the process 
tends to extend upon non-hairy parts of the face. While 
exceptionally eczema is confined to the hairy portion of 
the face, this is always so in sycosis. Eczema itches, 
sycosis does not. The duration of the disease will at times 
help us to a diagnosis, sycosis being far more chronic than 
is eczema. In syphilis, when the beard is involved, we 
will find pustules upon other portions of the body, and 
the history will help us to a correct conclusion. Further, 
the pustules or papules of syphilis are grouped in circles 
and segments of circles, are of a peculiar color, and their 
development is painless and comparatively slow. Acne 
is scattered about the whole face, and is usually met with 
in young persons. Comedones are present, and the pap- 
ules, pustules, or tubercles have no definite relation to the 
hair. The course and history of lupus are so different 
from those of sycosis that it is hardly possible for them 
to be confused. In lupus vulgaris we have the charac- 
teristic brown tubercles, which do not contain pus, are 
not confined to the hairy portions of the face, generally 
begin in early life, and tend to ulcerate or to be absorbed 
and leave behind cicatrices. 

Treatment. — The treatment of sycosis is both general 
and local. While many cases will yield to local treatment 
alone, there are quite as many, if not more, which require 
general treatment. The surroundings of the patient must 
be inquired into, and his mode of life, and we should 
endeavor to put him in as good a hygienic condition as 
possible. He should be advised against exposing himself 
to dust and wind, and then only with his face powdered 
or protected with ointmnet, and even against smoking, 
especially in a wind where the smoke blows against the 
face. The proper regulation of the diet is important. 
Many cases will improve if we stop their tea, coffee, hot 
drinks of all sorts, ale, beer, and spirits. If the digestive 
process seems at all embarrassed, it is well to put the 



SYCOSIS 627 

patient on a light diet for morning and evening, and 
direct him to take his principal meal at noon, eating 
meat only at that time. Anything that is known to him 
to be indigestible must, of course, be prohibited. In a 
word, the diet and hygiene of the patient should be 
regulated. 

What medicines we should administer will depend upon 
the stage of the disease. In the acute stage, when there 
are much swelling and inflammation, a good dose of blue 
pill, calomel, or some other active cathartic is to be 
ordered, to be followed by an alkaline diuretic. 

Small doses of calomel, T V of a grain, three times a 
day, for two or three days at a time, are useful in reliev- 
ing the congestion of the skin. In chronic cases iron, 
cod-liver oil, and other tonics are indicated if there is a 
state of debility. Arsenic is advised in very obstinate 
cases. If indigestion is present, we must address our 
remedies to its relief before we give arsenic or other 
remedy for the disease proper, and then we will probably 
have no need of so-called specifics. 

The local treatment must vary with the condition found, 
whether it be acute or subacute, and is more important 
than the general treatment. When the disease attacks 
the upper lip the nose must be examined for evidences of 
catarrh, and that condition treated if found. 

In the management of an acute case of sycosis soothing 
remedies are needed. Hot water should be sopped upon the 
part for some five or ten minutes once or twice a day, and 
this should be followed, if the beard is growing, by the 
use of a simple oil, such as olive oil or sweet almond oil; 
or if the face is shaved, the zinc oxide ointment or cold 
cream may be used; or better still, Lassar's paste, as 
follows : 

1$ — Amyli, i 

Zinc oxidi, aa 3ij aa 8| 

Vaselini, ad §j ad 32 1 M. 

Powdering the part with corn starch, or bismuth and 
talc, after smearing on a little vaselin, will at times give 
ease and comfort. 



628 DISEASES OF THE SKIN 

In the early stage, if the inflammatory symptoms are 
not very intense, a mild white precipitate ointment will 
sometimes check the disease. Duhring recommends bath- 
ing the face with "black wash," followed by zinc oxide 
ointment with a dram (4) of alcohol or a half dram (2) of 
camphor to the ounce (32), spread on cloths and bound 
on; and speaks well of oxide of zinc ointment with 15 to 
30 (1 to 2) grains of calomel to the ounce. 

When the disease has reached the pustular stage, and 
there is more or less crusting, the crusts are to be removed 
by the free use of olive oil, or oil of sweet almonds with 
2 per cent, of salicylic acid, letting it soak in thoroughly 
over night and washing the part with soap and warm 
water the next morning. If the crusts are thick, it is a 
good plan to tie up the bearded face in a towel after 
anointing it with oil. After the crusts are gotten rid of, 
the hairs should be pulled out of the pustules and epila- 
tion continued until pustules cease to form. The patient 
must be made to understand that epilation is necessary 
both for the cure of the affection and the salvation of the 
hair. After epilating, the oxide of zinc ointment, Lassar's 
paste, or diachylon ointment is to be used. Shaving is 
recommended, but it seems to me better to content our- 
selves with cutting the hair short. Shaving is prone to 
irritate the skin, and certainly would favor the dissemina- 
tion of the pus organisms. Sulphur in the form of an 
ointment, \ drachm to 1 drachm (2 to 4) to the ounce 
(32), or in powder, is a valuable remedy, though some- 
times it is too irritating. 

Instead of an ointment we may use oxide of zinc, 1 
drachm (4) to the ounce (32) of linseed or other oil. 
Shoemaker advises the application of equal parts of oleate 
of mercury and olive oil. 

In subacute and chronic cases a more active treatment 
is necessary. Here our aim is not so much to allay 
inflammation as to stimulate the skin. To this end we 
may use the soap and sake treatment of Hebra, which 
renders such good service in chronic cases of eczema. 



SYCOSIS 629 

In some cases better results will be attained by the 
use of diachylon ointment, or Lassar's paste with 10 or 
15 grains (0.66 to 1) of salicylic acid to the ounce (32). 
In very obstinate cases in which there is much thickening 
of the skin green soap may be kept applied to the part 
like an ointment. When sufficient inflammatory reaction 
is produced emollient measures, as in the acute stage, 
should be used. 

Our success in treating these cases will vary with the 
thoroughness with which the dressings are applied. All 
ointments must be spread on cloths, not on the skin, and 
the dressings must be kept continuously in close contact 
with the affected part. Sometimes a sulphur ointment, 
J drachm to 2 drachms (2 to 8) to the ounce (32); an oint- 
ment of iodide of sulphur; the ointment of the ammoniate 
(gr. xv-xxx ad §j) or the nitrate (3;HJ ad 5j)> or the 
red oxide (gr. v-xv ad §j) of mercury will prove useful. 
Robinson recommends the following ointment. 



1$ — Ungt. diachyli (Hebra), 
Ungt. zinc oxidi., 
Ungt. hydrarg. ammon., 
Bismuth, subnitrat., 



giss 


aa 


48 


3hj 




12 


3iss 




6 



M. 



He has found cod-liver oil the best local application in 
strumous subjects. 

Behrend has obtained good results by scraping the 
affected parts with the dermal curette and dressing with 
a simple ointment or oil. All abscesses must be opened. 
In some cases the following ointment has given me 
satisfaction after other combinations have failed: 



— Ac. salicylic, 


gr. x 


! 66 


Sulph. colloidal, 


5j 


4 


Eucerin, 


3vj 


24 i 


Adipis anserini, 


ad gj 


32 


01. rosse geran., 


gtt. XV 


1 M 



Solutions of the bichloride of mercury, 1 to 1000; or 
of resorcin in alcohol 5 per cent, strength, after shaving, 
may be used. Tumenol in 10 per cent, ointment at times 
is excellent. 



-/S-naphtol, 


gr. xv 


Spts. sapo. viridis, 


5vj 


Alcoholis, 


5iss 


Bals. Peruv., 


3ss 


Sulph. loti, 


3iiss 



630 DISEASES OF THE SKIN 

Kaposi recommends the following: 

ai 

45 
2 
10 M. 

The ammonio-sulphate of ichthyol and other drugs 
used by cataphoresis are commended. 

Boric acid does good in some cases. To assure against 
a relapse it is necessary to continue making applica- 
tions to the skin for four or five months after apparent 
recovery. 

The x-rays have a brilliant curative effect in sycosis. 
MacKee advises giving a massive dose of H. 4 and B. 8 
to 10. It is well to use some one of the antiparasitic 
lotions or ointments while using radiotherapy. The use 
of staphylococcic vaccines has its advocates. According 
to Engman, the results usually obtained from the treat- 
ment of this disease by stock or autogenous vaccines are 
not satisfactory unless hot packs are used, for obvious 
reasons. The disease is purely follicular with the guard- 
ing wall of the follicle to protect the cocci from influx of 
fresh lymph. Hot packs under an impervious cover 
applied three or four times a day change conditions 
materially. The dose varies as in furunculosis. 

Prognosis. — This is one of the most obstinate of 
diseases. Left to itself, when once under headway it 
shows no tendency to get well, and has been known to 
last twenty or thirty years. Even under the most judi- 
cious treatment it is an obstinate disease, taking weeks 
or months before a cure is effected. Relapses are exceed- 
ingly liable to occur, and these sometimes show a dispo- 
sition to recur at certain seasons. Unless the hair is 
carefully plucked from the inflamed follicles permanent 
baldness may be caused. But the disease is not danger- 
ous to life, and it is curable. 

Syphilis. — Synonyms: Malum venereum; Lues; Morbus 
Gallicus, seu Italicus, sen Hispanicus, sen Neapolitanus, 



SYPHILIS 631 

'Seu Indicus; (Fr.) Verole, or Grosse verole; (Ger.) Lust- 
seuche; (Eng.) Bad disorder, Pox. 

Large books have been written upon this disease. 
Here we can give only a brief outline of it, and that 
as it affects the skin alone. For a further account the 
reader should consult the larger special treatises. 

Symptoms. — Syphilis may be acquired or hereditary. 
It is acquired by local infection, the first manifestation of 
which is the appearance of the initial lesion, commonly 
called the chancre or hard sore. In probably 90 per 
cent, of the cases this initial lesion is located on the 
genitals, and in the vast majority of these its site in males 
is the glans and prepuce. But the initial lesion may be 
found on any part of the body, and within the mucous 
cavities. According to a table of 198 extragenital 
lesions compiled by Pospelow, 1 the female breasts were 
affected in 69 cases; the lips in 49 cases; the throat in 
46 cases; and then in very much less frequency the 
gums, tongue, chin, eyelids, nose, trunk, anus, arms, and 
legs. Some obscure cases of syphilis are due to the 
initial lesion being in the urethra or upon the cervix 
uteri or deep in the throat, and thus escaping detection. 

The initial lesion appears within two to six weeks after 
inoculation with the syphilitic poison; usually the inter- 
val is less than four weeks; exceptionally it may be ten 
weeks. This is the period of incubation. Opinions are 
divided as to whether the initial lesion is a purely local- 
ized lesion or the expression of a general constitutional 
infection that first declares itself at the point of inocula- 
tion. The initial lesion may assume the form of a scaly 
patch, a dry or moist papule, a superficial erosion, or a 
circumscribed ulcer with perpendicular edge. Induration 
of the base is a characteristic of all forms of initial lesion ; 
it is sharply defined and imparts to the fingers a distinct 
resistance that may be as firm as cartilage. Commonly 
it is parchment-like. To detect it, the lesion must be 

1 Arch. f. Dermat. u. Syph., 1889, xxi, .59. 



632 DISEASES OF THE SKIN 

gently pinched between the thumb and finger. It is 
present coincidently with the appearance of the initial 
lesion or within a few days afterward. It remains for a 
long time after the disappearance of the lesion — for two 
or three months or longer. The secretion from the initial 
lesion, when present, is thin and chiefly serous. The 
duration of the lesion is variable; it may disappear 
before the outbreak of cutaneous symptoms, but very 
often remains for some time after this event. Unless 
there has been ulceration, no cicatrix will be left. It 
may leave a staining of the skin or an induration. It is 
usually a solitary lesion, though it may be multiple. 
Taylor 1 says it is not uncommon to see from three to 
thirteen chancres which appear successively either due to 
auto-infection, or infection from two individuals. En- 
largement of the nearest lymphatic glands accompanies 
the initial lesion. If on the external genitals, it will be 
those of one or both groins. They become hard and are 
painless and freely movable. Suppuration is rare, and 
probably the result of mixed infection. A pleiad of 
glands, three arranged in a triangle, is quite character- 
istic of syphilitic infection. In women initial lesions are 
often so small and last so short a time that they are not 
noticed. In them induration is often not noticeable, 
and the diagnosis is much more difficult than in men. 
They are found on the external genitals, within the 
vagina, and on the cervix uteri. 

The initial lesion may at first assume the character of 
the soft sore. This is the result of mixed infection with 
both the virus of syphilis and of the local venereal ulcer. 
The ulcer will after a while become indurated and as- 
sume its proper characteristics. It is in these cases that 
a suppurating adenitis may develop. Modifications 
from location of the initial lesion must also be noted. 
(1) Of the urethra: A chancre may be at the meatus, 
in the fossa navicularis, or deeper parts. At the meatus 

1 Jour. Cutan. Dis., 1906, xxiv, 401. 



SYPHILIS 633 

it attracts attention by causing a slight impediment to 
urination. The lips are found glued together by a scanty 
viscid secretion. The normal opening of the urethra 
becomes lessened by the induration, which usually 
involves the entire circumference of the meatus. If 
located deeper down, it may give rise not only to inter- 
ference with urination, but also to some pain, and later 
to a mucopurulent or purulent discharge like that of 
gonorrhea, because it causes a urethritis. It may be 
felt as a hard, tender, circumscribed nodule, and be seen, 
with the endoscope, as a grayish-red erosion of the 
urethral wall. It may give rise to symptoms of stricture. 
(2) Of the anus: A chancre may be without the anus, 
at its margin, or within the anal ring, and usually presents 
a thickened, fissured, ulcerated surface. It is of a pale- 
rose tint, and decidedly indurated. (3) Of the fingers: 1 
An initial lesion may be seated at any part of the phal- 
anges, but most often at the sides or base of the nail, or 
at its free margin. It begins as a papule, pustule, ex- 
coriation, or fissure, and attracts attention as an obstinate 
hang-nail or fissure; or as an irregular, deep-red, some- 
what elevated mass that is ulcerated and covered with a 
scanty serous secretion. The finger is apt to be swollen 
at its end. The epitrochlear and axillary-ganglia are 
enlarged, and there may be moderate lymphangitis. 
(4) Of the lips: This chancre is usually covered with a 
greenish-brown crust, which, when removed, leaves either 
an erosion of little, if any, hardness, or an ulceration of 
cartilaginous consistence. It may begin as a fissure or 
painful excoriation. The lips may be greatly swollen. 
Either the upper or lower one may be affected; usually 
only one. The submaxillary glands on the side of the 
lesion are commonly first affected. (5) Of the tongue: 
Here we meet with a hard, circumscribed, flat, slightly 
elevated, dull-red, smooth, pea-sized nodule; or a round, 
sharply defined, fleshy red, raised, hard ulcer. The 

1 An admirable study of these lesions by Dr. R. W. Taylor will be 
found in the Medical Record, 1891, xxxix, 69. 



634 



DISEASES OF THE SKIN 



cervical and submaxillary glands are enlarged. (6) Of 
the throat: The patient first notices difficulty or pain in 
swallowing, the latter in the region of the tonsils. Then 
the submaxillary and cervical glands become swollen. 
Examination shows an intense, limited or diffused, gen- 
eral or unilateral, brown or dark redness of the pharynx. 
The tonsils are enlarged, hard, and red, and may be 
eroded, and perhaps covered with an ash-colored deposit 
—a false membrane. Or we may find an irregular, hard 
ulcer with gnawed-out edges, and, it may be, crater- 
shaped floor covered with dirty brown or grayish deposit. 
One or both tonsils may be affected. (7) Of the nipple: 
Chancres of the nipple are usually multiple, and may 

Fig. 92 




Chancre of the lips. (By the courtesy of Dr. S. D. Hubbard.) 



take the form of an erosion, a scaly patch, or an indur- 
ated fissure. The size varies from that of a lentil up 
even to three inches in diameter. They are sometimes 
linear, sometimes sickle-shaped along one side of the 
nipple, and sometimes completely encircle the nipple. 
The nipple is red or dark, enlarged, hardened, and at 
times flattened. Mastitis may complicate matters. 
The axillary glands are enlarged, as are often those along 
the upper edge of the pectoralis major. On healing the 
initial lesion leaves a flattening of the nipple, and per- 
haps a leaning of it to one side, characteristics that should 
put us on our guard in the examination of wet-nurses. 
About six weeks after the appearance of the initial 



SYPHILIS 635 

lesion (it may be as early as the twenty-fifth day, or as 
late as the one hundred and sixtieth), we have the stage 
of eruption of the so-called secondary syphilides. Usually 
just before the outbreak of the eruption, or shortly 
after it, examination will show a general enlargement 
of the lymphatic glands, especially the epitrochlear and 
postcervical. At the time of the eruption, or shortly 
before, the patient may experience certain constitutional 
disturbances, such as severe headache, malaise, pains in 
the joints, and a rise of temperature of moderate extent. 
In very many cases these disturbances either do not 
exist, or are of so slight severity as not to attract the 
patient's notice. In some cases a more or less profound 
anemia will manifest itself, or the patient will fall into 
a markedly cachectic condition. Either of these may 
last far into the secondary period of the disease. Weakly 
individuals are more prone to these severe constitutional 
derangements than are the robust, and Fournier teaches 
that they are most apt to appear in women. 

The eruptions of syphilis are, for convenience, divided 
into two groups named, respectively, secondary syphilides 
and tertiary syphilides; or the early and late lesions. No 
hard-and-fast lines can be drawn, as sometimes those 
lesions usually seen late in the disease manifest themselves 
early in its course. The secondary syphilides are those 
that develop during the first two years after infection. 
They are marked by a more or less general and symmet- 
rical dissemination over the whole cutaneous surface; by 
polymorphism; by running a rather definite course; by 
implicating the more superficial parts of the skin and 
mucous membranes; and by leaving little, if any, trace of 
themselves. In these respects they differ from the lesions 
of late syphilis, which are grouped and limited to certain 
regions, are not polymorphic, show less tendency to run 
a definite course, involve the deeper structures, and are 
prone to leave permanent scars. 

The eruptions of secondary syphilis are the erythema- 
tous, the papular, and the pustular syphilide. The first 



636 DISEASES OF THE SKIN 

eruption of the secondary stage is usually an erythema- 
tous one, the macular syphilide, or the syphilitic roseola. 
Unlike other syphilides, which are all largely composed of 
new cell-growth, this may be a hyperemia without cell- 
infiltration. It may be a general eruption, though usually 
most marked upon the sides of the trunk and flexor 
aspect of the limbs. The macules are about the size of 
a ten-cent piece, or smaller, of a faint rose-red color, 
circular in form, and little if at all raised above the 
skin. At times we meet with annular lesions from dis- 
appearance of the centre of the macule. This is especially 
seen in the colored race. The lesions excepting in relaps- 
ing eruptions, are distinct from each other. They become 
more evident on exposure to cold, it being no uncommon 
thing to see them appear upon the patient's body while 
he is before us stripped for examination. After being 
out for a time their color becomes purplish red, changing 
to a tawny or yellowish red, and later to a brownish 
yellow. In their early stage they can be made to dis- 
appear on pressure. They either disappear and leave 
no trace or some pigmentation, or they develop into 
papules. The evolution of this eruption usually requires 
a week or ten days; sometimes it may be much less. 
The duration of the eruption is from one to three months 
if not removed by treatment. Relapses occasionally 
occur, and these may be met with as late as the end of 
the first year. Then it is usually limited to certain 
regions. It gives rise to no inconvenience, and is often 
overlooked by the patient except when it appears on the 
face or hands. At this time there are apt to be an ery- 
thematous condition of the pharynx, some sore throat, 
a rheumatoid affection of the joints, falling of the hair, 
perhaps an iritis, and mucous patches in the mouth, 
upon the vulva, in the groin, upon the scrotum and under 
surface of the penis, and about the anus. 

While the diagnosis is easy, if we have seen the patient 
from the time of the initial lesion, in some cases we must 
differentiate between it and mottling of the skin; an 



SYPHILIS 637 

exanthem; a medicinal eruption, chromophytosis ; and, if 
we have annular macules, trichophytosis corporis. From 
mottling of the skin it is diagnosed by the fact that in 
syphilis we have macules of a reddish tint interspersed 
with skin of normal hue, while in mottling we have light 
macules with dull purplish-red interspaces. From an 
exanthematous fever it is diagnosed by the absence of 
catarrhal or gastric symptoms and marked pyrexia, 
and by the sluggish character of its lesions. From a 
medicinal eruption it is diagnosed by an absence of gastric 
disturbance, and by its lesions lacking the urticarial or 
edematous character. From chromophytosis it differs 
in having a red rather than a cafe-au-lait color, by not 
being scaly nor capable of removal by scraping, by its 
more extensive distribution, and by the absence of the 
microsporon furfur from the scales when they are examined 
under the microscope. From trichophytosis it differs in 
the greater extent of its distribution, and in the absence 
of the trichophyton fungus from scales scraped from the 
skin. From pityriasis rosea the differentiation is some- 
times difficult when the syphilitic macules have assumed 
a ring-form. As a rule, there is no difficulty, as a pity- 
riasis rosea will be scaly, and will present not only rings, 
but macules of all sizes, while the syphilitic macules are 
not scaly and are of more uniform size. 

The papular syphilide, while usually following the 
erythematous syphilide, may be the first eruption of the 
disease. Indeed, a great many cases begin as a maculo- 
papular eruption. The papules may develop from macules 
or may appear as papules. Very commonly both macules 
and papules will be present at the same time. If it fol- 
lows the macular form, it is apt to appear while the 
latter is fading. The eruption consists of a greater or less 
number of firm, rounded, fleshy, red elevations of the skin, 
varying in size from that of a pinhead to one inch in 
diameter. After continuing unchanged for a certain time 
they undergo absorption; the oldest or central part of the 



638 DISEASES OF THE SKIN 

papule disappears first, sinks in a little, and becomes scaly. 
It is then that slight pruritus may be complained of. 
They are scattered over the whole cutaneous surface, and 
often appear in well marked groups with somewhat of a 
crescentic arrangement. They are prone to relapses, and 
sometimes are seen as a relapsing eruption in the tertiary 
stage of the disease, when they do not occur as a general 
eruption, but in groups upon one or more regions of the 
body. According to their size, they have received the 
names of the lenticular and miliary papular syphilide, the 
former being the larger and most common eruption. 

The lenticular papular syphilide is a hemispherical or 
flattened, firm, fleshy, lentil- to split-pea-sized promi- 
nence with a smooth and glossy surface. Not infrequently 
the superficial layer of epidermis over it is wanting from 
the central portion and slightly detached around the base, 
forming a fringe called the collarette of Biett. This is 
regarded as a diagnostic symptom. The color of the pap- 
ule is at first light red; later it assumes a raw-ham color 
that is best seen on the legs. From the knee down it 
may have a purplish or hemorrhagic appearance. Such 
papules are usually present in great number and scattered 
over the whole body. On the face they are apt to locate 
along the hair-line on the forehead, forming the corona 
veneris. On the scalp they are not very numerous, and 
are apt to become papulopustules and crust; or they 
itch slightly and are scratched. The palms and soles 
are usually well covered in any general outbreak of them. 
Here they appear as reddish spots under the thick epi- 
dermis, and a little later than on the rest of the body on 
account of the thickness of the epidermis retarding their 
outbreak. Desquamation is often seen over the papules 
on the palms and soles. Sometimes the eruption is very 
slight in extent, only a few scattered papules being found. 
This syphilide develops slowly, runs a course of one or 
two months, and disappears, leaving pigmentation or 
slightly depressed spots neither of which is permanent. 
In undergoing resolution the papules may become scaly 



SYPHILIS 



039 



and form a papulosquamous syphilide, or pustules may 
form on them during their course, and we then have the 
papulopustular syphilide. 

While the form of the lenticular syphilide just described 
is the typical one, we see at times larger papules, from 
three-eighths to half an inch in diameter, forming the 
discoid or large, flat, papular syphilide. This rarely, if 
ever, is a general eruption, but is limited to certain 
regions. It may occur alone or with the lenticular 

Fig. 93 




Papular syphilide of palms. (By the courtesy of Dr. S. D. Hubbard.) 



syphilide. It usually follows the latter or appears when 
it is fading. It frequently comes as a relapsing syphilide, 
and often appears late in the second year. It has a 
flattened surface and a circular outline. The lesions 
often coalesce and form patches which frequently become 
scaly and resemble psoriasis. The scaling is never very 
great; the scales are thin and adherent, and do not cover 
the whole patch. They frequently occur upon the flexor 
aspect of the extremities and in the bends of the joints. 



640 



DISEASES OF THE SKIN 



Instead of forming patches by coalescence, the individual 
papule may enlarge at the circumference and become 
depressed at the centre and form circinate lesions, whose 
surface may become moist. 



Fig. 94 




Annular syphilide. (Courtesy of Dr. H. Fox.) 

The moist papule or mucous patch is a modified form 
of the lenticular papule, and is simply a papule subjected 
to heat and moisture. It is found where two folds of skin 
rub together, as in the penoscrotal fold, between the 
scrotum and inside of the thigh, around the anus and 
vulva, and upon mucous membranes. It is of circular 
shape and has a flattened surface which is sometimes 
depressed in the centre. Newly formed ones have a 
bright-red or raw appearance, but they soon become 



SYPHILIS 641 

covered with a dirty whitish coating made up of thickened 
and softened epidermis. About the anus and vulva they 
form large flattened tubercules called condylomata lata 
(Fig. 95). They give forth a most offensive odor when not 
kept clean. When in the mouth they form "opaline 
patches/' looking as if the mucous membrane had been 
penciled with nitrate of silver. They are usually not 
elevated. If at the angle of the mouth, they are generally 
fissured. The mucous patch is one of the most conta- 
gious of syphilitic lesions, the evidence of infection being 
an initial lesion of syphilis, and not a mucous patch. It 
is also at times, especially when it comes late in the dis- 
ease, most obstinate to treatment, and inclined to relapse 
during many years. 

Fig. 95 




Condyloma lata. (After Taylor.) 

The miliary papular syphilide is much rarer than the 
other form of papular syphilide; in fact it is one of the 
least common of the syphilides. The eruption consists 
of numerous pinhead- or slightly larger-sized conical 
papules of a purplish-red hue, either disseminated over 
the whole body or aggregated in groups forming circles 
or segments of circles. They are developed about the 
hair follicles and have depressed centres. Many of them 
may be surmounted by a small vesicle or vesicopustule. 
41 



642 DISEASES OF THE SKIN 

This constitutes what has been named the vesicular 
syphilide. Sometimes the lesions when closely pressed 
into patches may be scaly. It may be an early lesion or a 
relapsing later one. In the latter case the eruption is not 
abundant, but in groups. The color is brownish-red, and 
pigmentation and permanent pitting are left by the 
lesions, if they have lasted any time. They rarely change 
into condylomata. Their evolution is rapid, being fully 
developed within two weeks. Pea-sized conical papules 
sometimes are seen among the miliary ones. 

When the papules form groups, bearing a fancied 
resemblance to a bunch of grapes they are spoken of as 
corymbiform. 

The diagnosis of the papular forms of syphilis is gen- 
erally easy because other symptoms of the disease will be 
sure to be present and to establish the diagnosis. It is 
possible that error may arise in distinguishing the patches 
of scaling papules from psoriasis, but here the location of 
the patches upon the flexor surfaces of the extremities, 
and over the bends of the elbows; the scaling not being 
commensurate with the patch, but having a dull red, 
sharply defined border about it; and the well-marked 
infiltration of the patches, are all features that would 
throw out the diagnosis of psoriasis. The miliary papular 
syphilide may be confounded with lichen planus or 
keratosis pilaris, but the absence of itching is always in 
favor of a syphilide; and the conical or rounded shape of 
its papules is in strong contrast with the flat, angular, 
and umbilicated papule of lichen planus. The syphilide 
is also a much more widely disseminated eruption than is 
lichen planus or keratosis pilaris likely to be, and is 
never seen confined to the anterior face of the wrists as 
is lichen planus. 

The pustular syphilide is the last eruption belonging to 
the secondary stage that remains to be described. It is 
always evidence of a poor condition of the health of the 
patient who bears it. It may be the first eruption of 



SYPHILIS 643 

syphilis, or follow the erythematous or papular form, or 
occur later. It may develop from a macular or papular 
syphilide, or occur with either of them. It may occur as 
a relapsing eruption late in the tertiary period. It is held 
by some authorities that it is always the product of 
infection of a syphilide by pus organisms. The appear- 
ance of this form of syphilide is not infrequently accom- 
panied by fever. It may assume varying forms and sizes, 
to which in the faulty nomenclature of the older writers 
have been given the names of non-specific lesions, greatly 
to the confusion of the student. 

The lenticular pustular syphilide (variola form) occurs 
as a disseminated eruption of small hemispherical, pea- 
sized pustules, having a hard, papular base and more or 
less of an inflamed areola. It may develop by the soft- 
ening of a papule or be a papulopustule from the start. 
In the latter case its eruption will be marked by fever, 
which is apt to recur with each succeeding outbreak. The 
eruption may be general or upon certain regions. The 
lesions are discrete, and do not form marked groups, 
although in the pustular eruptions, as in others, it is easy 
for one who looks for them to find groupings in circles 
and segments of circles. A few days after they appear 
they begin to dessicate, and the larger ones may umbili- 
cate. At this stage they become crusted with a dirty 
yellow, brownish, or greenish-brown crust. This falls 
soon and leaves a transient pitting and pigmentation. 
Relapses may occur. 

The miliary pustular syphilide (acne-form). The erup- 
tion consists of millet-seed- to pinhead-sized acuminate 
pustules developing generally from papules and occurring 
in small groups of about the size of a quarter- or half- 
dollar. It may occur as a general eruption, but is apt 
to be more marked and lasting on the extremities than 
on the trunk. The lesions, especially when occurring 
upon the flexor aspect of the joints, are liable to coalesce. 
They are developed in and around the hair follicles, and 
may be perforated by hairs. They are topped with small 



644 DISEASES OF THE SKIN 

crusts. The eruption lasts two or three months by the 
outbreak of new lesions, unless controlled by treatment. 
It leaves pigmentation and pitting that may remain for 
several months. 

While these are the two chief varieties of the early 
pustular syphilide, there is another variety that is called 
the impetigo-form syphilide, which occurs most commonly 
in the middle or latter part of the first year of syphilis. 
It may occur as late as in the third year. In it the pus- 
tules are small and flat, and by confluence an impetiginous 
crust is produced. They may form patches with crusting 
only at the border. This form is met with usually on the 
face, arms, and thighs. A few superficial ecthymatous 
lesions may develop, but ecthymatous lesions are usually 
late manifestations. 

The diagnosis of the pustular syphilide is usually easy 
from the presence of other symptoms of the disease. The 
lenticular form may be mistaken for variola or varioloid. 
It differs from these in the infiltrated bases of the pustules, 
in being composed of lesions of varying size and age, in 
not occurring in the mouth, and in not running a definite 
rapid course. The miliary form might be mistaken for 
acne, but it is never confined to the face, chest, and back 
as is acne, nor does it present comedones, and so great 
multiformity of lesions. 

Tertiary Syphilides. — The erythematous, papular, and 
pustular syphilides are those eruptions that occur in the 
early months of syphilis and during the first year. As 
we have seen, thay may also constitute relapsing eruptions 
later in the disease. Modifications of them may occur 
late in the secondary period or even in the tertiary period. 
Besides these, we have a second group of syphilides that 
occurs any time after the first year, and sometimes as late 
as twenty or more years after the initial lesion, when the 
patient may have lost all remembrance of it. To these 
eruptions the name of tertiary or late syphilides is given. 
Their peculiarities have been indicated in a general way 



SYPHILIS 645 

when writing of the early syphilides. They are the 
tubercular, or nodular, the squamous, the pustulo- 
crustaceous, the gummatous, and the ulcerative syphilides. 
Exceptionally these eruptions may occur before the 
second year, when they are to be regarded as precocious 
lesions. 

The tubercular or nodular syphilide occurs in the latter 
part of the second year of syphilis, or later. Exception- 
ally it may occur during the first year as a so-called 
precocious syphilide. As a rule, the early syphilides 
cease appearing after six or seven months, and then after 
a varying interval of rest the late lesions appear. These 
may never come at all, usually as the result of judicious 
treatment, or it may be because of the vigorous resistance 
of the constitution of the individual. 

Nodular lesions occur in the form of clustered nodules 
in the deeper part of the corium. At first they are of 
faint-red color; gradually they become a dull red, and 
later still darker. In size they vary from that of a split 
pea to that of a hazelnut, and constitute firm, elastic, 
fleshy protuberances. They are round, smooth, and 
somewhat glossy, or flat, rugous, and withered. They 
are frequently scaly. Most often they are arranged in 
circles or segments of circles; or they may be in the 
form of rings from the first, or in consequence of the 
disappearance of the central members of the group (Fig. 
96). There may be but a single group; or numerous 
groups may be scattered over the body in asymmetrical 
manner. A very frequent location for them is the pos- 
terior portion of the neck or on the face. The later in 
the course of the disease they occur, the more they 
are apt to form but a single group. If uninfluenced 
by treatment, nodules may continue to form for years, 
the old ones disappearing and new ones coming. They 
disappear either by absorption, or by softening or break- 
ing down and forming a sharply-cut ulcer with perpen- 
dicular edges and yellow sloughing base. A number of 
the lesions breaking down at once and coalescing, a large 



646 



DISEASES OF THE SKIN 



ulcer with scalloped border, indicating its composition 
from single lesions, and with more or less thick greenish 



Fig. 96 




Nodular syphilide. (Courtesy of Dr. H. Fox.) 



crust, will form. In either case they leave depressed, 
smooth cicatrices, at first pigmented, but later white. 



SYPHILIS 



64; 



They give rise to no subjective disturbances. Rarely do 
they form a general eruption. 

The diagnosis of this form of syphilide is usually read- 
ily arrived at by finding other symptoms of syphilis. Oc- 
casionally it may be confounded with lupus vulgaris and 




Annulat nodular syphilide. (After Taylor.) 



leprosy. From lupus it is differentiated by the compara- 
tive rapidity of its course, lupus being a disease of exceed- 
ing slowness of development; by its occurrence in mature 
years, lupus being a disease of youth; by its sharp-cut 
round ulcers; by its thick greenish crusts, and by the 
smoothness of its cicatrices, those of lupus being puckered 



648 



DISEASES OF THE SKIN 



and deforming. Syphilis at times bears a striking re- 
semblance to leprosy when its tubercles are located in the 



Fig. 98 




Nodular syphilide. (By the courtesy of Dr. S. D. Hubbard.) 
Fig. 99 




Nodular syphilide. (Courtesy offDr. H. Fox.) 

eyebrows, face, and ears, but the absence of anesthesia is a 
positive diagnostic sign against leprosy. Moreover, other 



SYPHILIS 



649 



symptoms of leprosy, such as swelling of the ulnar nerves 
and peculiar brown patches, will be absent. 

The squamous syphilide is not usually described, as it 
is a modified form of either the papular or the tubercular 
lesion. In using the term here, I follow Dr. George H. 
Fox, and like him adopt it purely on clinical grounds. 

Fig. 100 




The circinate squamous syphilide. (By the courtesy of Dr. S. D. 

Hubbard.) 



He applies the term to scaly patches of circular or irreg- 
ular form that occur after the first year of syphilis. 
These patches are covered with t^in horny scales seated 
upon an infiltrated base. We may have one of two 
forms : the discoid or the circinate. The discoid form is 
almost peculiar to the palms and soles and neighboring 
parts, and constitutes the only apparent lesion. The 
round patch of varying size, but with a sharply defined 



650 DISEASES OF THE SKIN 

reddish seam beyond the scaling, and an infiltrated base 
tends to become serpiginous, creeping over a considerable 
portion of the skin. Sometimes while it advances at one 
border it heals at the other; at other times it clears up 
in the centre, leaving an elevated, scaling marginal ring. 
The ring may be broken and leave a curved line, and if 
two or more of these lines meet, we have a gyrate figure. 
Usually but one palm or sole is involved. The skin is 
apt to crack in the natural creases, and then the patient 
will suffer some pain and discomfort. It is always an 
obstinate lesion to cure, persisting sometimes for months 
or years. The circinate form differs from the one just 
described in being annular from the first, and in occur- 
ring not only on the palms and soles, but elsewhere on 
the body. It is often seen on the face, about the mouth 
and chin, and seems to be specially apt to affect the 
negro race. A seborrhea sicca frequently complicates it. 
Unna teaches that the lesion is a combination of sebor- 
rhea and syphilis. 

The diagnosis of this form of syphilide from a squam- 
ous eczema of the palm is often one of great difficulty 
Ths fact that only one palm is affected is always sug- 
gestive of syphilis. Moreover, in syphilis there is more 
infiltration and much less itching. Indeed, the latter 
may be entirely absent. In syphilis the lesion is often 
crescentic, with sound skin between the horns of the 
crescent. This is never seen in eczema. Psoriasis of 
the palm is in most cases not to be thought of as a stum- 
bling-block in diagnosis, as it is exceedingly rare for 
psoriasis to affect the palms, and then only as a part of a 
general outbreak of the disease. Some writers use the 
term syphilitic psoriasis for the scaly palmar syphilide, 
but it is a most faulty method of nomenclature. 

The pustulocrustaceous syphilide is characterized by 
large and usually deep-seated pustules or ulcers, covered 
by prominent and peculiar crusts. It is the ecthyma- 
form of R. W. Taylor and other authorities. It occurs 
as a late and localized form of the disease; never as a 



SYPHILIS 651 

general eruption. It may occur as a precocious syphilide. 
It is seen in debilitated subjects, and is of gradual de- 
velopment, without febrile symptoms as in the pustular 
syphilide. It has preference for the scalp, face, and 
extremities. It assumes three forms, the ecthymatous, 
rupial, and pemphigoid. 

The ecthymatous form begins as an eruption of one or 
more round, flat pustules of a diameter of one-quarter to 
one-half inch. They may become as large as a silver 
half-dollar. They have a well-marked inflammatory 
areola and a swollen and indurated base. The pus soon 
dries and forms a flat, greenish or brownish-black crust, 
whose centre is sometimes depressed. At first the crust 
fully covers the pustule, but later, either through drying 
or on account of an increase in the size of the pustule, a 
raw rim is left around it. When it is now removed it 
exposes a typical punched-out ulcer with its base covered 
with sanious pus, which rapidly dries into a new crust. 
Under proper treatment the pustule heals, and when the 
crust falls there will be left a healed or nearly healed 
ulcer. A permanent cicatrix is left when healing is com- 
pleted, which is smooth and white eventually. This 
syphilide is seen most often on the legs and arms. If the 
course of the disease is not checked, the crust is cast off 
by increased suppuration, and the ulcerative syphilide 
is before us. 

The second variety of the pustulocrustaceous syphilide 
is that which is commonly known as rupia. It differs 
from the preceding variety in being more superficial at 
the beginning, and in forming a conical, laminated crust 
somewhat resembling an oyster shell. It begins either 
as a superficial pustule or as a small flattened bulla with 
no inflammatory induration. Upon the primary lesion a 
greenish crust develops, under which ulceration, with 
suppuration, occurs. The margin of the ulceration 
extends a little beyond the original crust. A new crust 
forms upon it, raising up the original one, and this pro- 
cess being repeated, at last a laminated crust is formed. 



652 DISEASES OF THE SKIN 

When the ulceration extends more rapidly in one direc- 
tion than another it follows that the crust will be higher 
at one end that at the other. Crusts may form a half- 
inch or more in height, and one or two inches in diameter. 
If the lesions are numerous, they are usually small; if 
few, large. When these thick conical crusts are re- 
moved, the ulcer is exposed and is less deep than in the 
ecthymatous form. On healing, a permanent, smooth, 
white cicatrix is left at last. 

The third variety of the pustulocrustaceous syphilide 
is the pemphigoid or bullous form. It is a very rare 
lesion in acquired syphilis, though quite common in hered- 
itary disease. It consists in an eruption of superficial, 
purulent, flattened bullae from 1 to 5 cm. in diameter, 
which tend to dry into thick crusts. They are surrounded 
by a dull red areola, and are soon covered by dark green- 
ish-black adherent crusts. If the patient be in fair 
health, the ulceration under the crusts will not be deep. 
If the patient be a broken-down subject, the ulceration 
may be very deep. It will leave either a pigmented 
atrophic spot or a pronounced scar, according to the 
depth of the ulceration. 

The diagnosis of the pustulocrustaceous syphilide is 
usually easy if the disease is known to the observer, as 
no non-specific disease resembles it closely. The so-called 
ecthyma cachecticum is more inflammatory than is the 
ecthymatous syphilide, and more superficial. The bullous 
syphilide often bears a striking resemblance to pemphigus, 
and can be diagnosed only by a study of all the features 
of the case. 

The gummous syphilide is perhaps one of the most char- 
acteristic of the late lesions of syphilis. It consists in a 
deposit of gummy material in the skin. The distinction 
between some tubercular lesions and a gumma is often 
very indistinct, and made principally by the size. The 
gumma begins in the subcutaneous tissue and involves the 
skin secondarily. It may take the form of a single tumor, 
a group of nodules, or a diffused infiltrated patch. It is 



SYPHILIS 



653 



Fig. 101 



nearly always a late lesion, and while it may undergo 
absorption it possesses a strong tendency to break down 
and ulcerate (Fig. 101). 

The single tumor begins as a small, pea-sized nodule, 
seated in the subcutaneous tissues so deeply as to be 
appreciated only by the touch. It grows slowly; in the 
course of weeks or months it may attain the size of a 
nut and push up the skin over it into an evident tumor, 
which is movable, firm, elastic, painless, and rolls under 
the finger. Increasing in size, 
it involves the skin, which 
then becomes of a dull reddish 
color. When the skin becomes 
involved the tumor is no longer 
movable, and soon fluctuation 
may be felt that would lead 
the inexperienced to open it 
as an abscess. If he did so, 
it would be a mistake. He 
would find only a little pus, 
a gummy substance, and some 
blood. Left to itself, the tumor 
may be absorbed, or it may 
break down and ulcerate, leav- 
ing a characteristic deep and 
round ulcer. The scalp and 
forehead are the chosen sites 
for this syphilide, though it 
may occur anywhere. It some- 
times attains a large size — as large as a hen's egg. When 
this lesion occurs as a precocious syphilide it is usually 
of small size and multiple. 

When gummas occur in the form of grouped nodules, 
the skin between them is apt to become infiltrated with a 
gummatous deposit, and the patch will present the dull 
brownish-red color of the late syphilides. The individual 
members of the group run a course similar to that of the 
isolated gumma, but do not attain its size. When they 




Gummas. (After Jullien.) 



054 DISEASES OF THE SKIN 

break down they form a large irregular ulcer. This 
variety of the gumma is frequently met with upon the 
scalp, the nose, the outer aspects of the extremities 
about the joints, and around the lower portion of the leg 
and ankle. Diffuse gummatous infiltrations of the skin 
probably precede all serpiginous ulcerations. Apart 
from this it is rarely seen, and almost always ends in 
ulceration. 

Other gummatous deposits are known as syphilitic 
dactylitis, admirably described by R. W. Taylor, and 
syphilitic bursitis, carefully studied by E. L. Keyes. 
One being a bony and the other a synovial disease, they 
do not here concern us. 

The diagnosis of the gumma must be made with care. 
It may simulate other forms of tumors. It is not as hard 
as the sarcoma, nor as compressible as the lipoma, and it 
invades the skin. An abscess is usually attended by pain 
and signs of inflammation, and runs a more acute course 
than does the gumma. 

The ulcerative syphilide, according to Dr. George H. 
Fox, merits being described by itself, though in itself 
only a sequence of a tubercular, pustulocrustaceous, or 
gummatous syphilide, because in the majority of cases of 
syphilitic ulcers met with it is hard or impossible for 
us to say what the preceding lesion has been. For con- 
venience, he describes the superficial, the serpiginous, and 
the deep or perforating forms of syphilitic ulceration. 

The superficial syphilitic ulcer is circular, with sharply 
cut edges and dirty yellowish purulent base. It most often 
follows a pustular or pustulocrustaceous lesion, and may 
appear comparatively early in the disease, especially in 
debilitated subjects. It is usually of the size of a quarter- 
or half-dollar, and frequently coalesces with other ulcers 
to form ulcerative patches with scalloped margins. The 
face and legs are its most common sites. 

The serpiginous ulcer is so called because it tends to 
creep over the surface, healing by a cicatrix as it passes 
along. It may develop from a single circular ulcer healing 



SYPHILIS 655 

in the middle or at one side, and leaving a crescentic 
or "horseshoe" ulcer at the other side, with a sharp 
convex margin, beyond which is a narrow zone of infil- 
tration upon which the ulceration constantly encroaches, 
while healing at its concave border. Or a group of 
crusted pustules or softening tubercles form a number of 
small round ulcers, of which the outer ones usually make 
a curving line. While those in the centre and at one 
side tend to heal, new lesions develop at the periphery 
of the opposite side, which ulcerate and perhaps coalesce, 
and so the disease creeps on. This form is often observed 
upon the back and on the extremities; it is not par- 
ticularly painful, and the patient's health may not be 
impaired. 

The deep ulcerations of syphilis result, for the most part, 
from the breaking down of gummatous deposits. The 
small ones are crater-like in shape. Often the opening of 
the softened tumor is smaller than the softened mass, and 
it is not infrequent to find the cavities of adjacent tumors 
running together subcutaneously. 

Ulcerative syphilides sometimes are covered with exu- 
berant granulations. 

The diagnosis of syphilitic ulcers from non-specific 
ulcers is most important from a therapeutic stand-point. 
A chronic ulcer, if it is not syphilitic, is probably either 
traumatic, tubercular, or cancerous. The traumatic ulcer 
is acute and highly inflammatory; of irregular shape; 
has a history of traumatism, and heals rapidly, except- 
ing in very broken-down subjects, under simple dress- 
ings. The tubercular ulcer, if from broken-down caseous 
glands, has a history of the previous glandular affection; 
is irregular in shape; often presents a number of sinuses 
and ridges of inflamed tissues, and runs a sluggish course. 
If it is a lupous ulcer, there will be found somewhere 
in the neighborhood the characteristic apple-jelly-like 
tubercles; there will be a history of commencing in 
early life; the edges of the ulcer will be shelving or 
undermined, and there will usually be more or less 



656 DISEASES OF THE SKIN 

deforming cicatrices present. A cancerous ulcer, usually an 
epithelioma, will have a history of beginning in a pimple, 
wart, mole, or such like; will be irregular in shape with 
an uneven floor; will be apt to be attended by lancinating 
pain; will usually be a single lesion, located on the face, 
and will have a raised, waxy, rolled-out border, over 
which delicate bloodvessels will be seen to course. 

The diagnosis of ulcers of the leg lies between one of 
syphilis and of varicose dermatitis. If the ulcer is irreg- 
ular in shape with shelving edges, rather superficial, sur- 
rounded by a brawny, infiltrated, brownish or dark-red 
tissue with more or less scaling, and there are varicose 
veins above it, we have to do with the so-called varicose 
ulcer. This is in sharp contrast with the round or scal- 
loped bordered, deep, punched-out ulcer with perpen- 
dicular edges and greenish base, around which there is 
but a small zone of redness. The diagnosis of syphilis 
is strengthened when we find a number of ulcers, or the 
cicatrices of old ulcers. As a rule the syphilitic ulcer is 
located on the posterior surface of the upper half of the 
leg, while the varicose ulcer is on the anterior surface 
of the lower third of the leg. The diagnosis from a 
traumatic ulcer has already been given. 

Over the pigmentary syphilide there has been no little 
discussion. By this term is not meant pigmentation fol- 
lowing a syphilide, which is sufficiently common, and due 
to a staining of the skin with hematin, but a true pig- 
mentation without antecedent lesion, which is sometimes 
seen on the sides of the neck, especially in women. It is 
composed of irregularly round or oval spots, one-eighth 
of an inch to one inch in diameter, with ill-defined mar- 
gins, and cafe-au-lait color, which does not fade on pres- 
sure. The color may be very faint. The lesions may be 
discrete or confluent. When they are very numerous 
they have been compared by Fournier to a "network 
of lace with large meshes," and to it has been given the 
name of collarette of Venus. This is one of the rarer 
manifestations of syphilis. 



SYPHILIS 657 

Alopecia due to syphilis has already been described 
under the heading of Alopecia Syphilitica, which see. 

Syphilitic affections of the nails may be due to lesions 
of the nail-bed or matrix or both; or of lesions about the 
nail. In the first variety the nails are damaged in their 
nutrition, becoming brittle, furrowed, discolored, and 
broken; or they may become detached from the bed and 
fall. They may become thickened, but less commonly. 
In the second variety we have a paronychia, the nail 
furrow becoming swollen or perhaps ulcerated. 

General Diagnosis of Syphilis. — In any case of 
doubt in diagnosis of an eruption we have three methods 
of investigation to which to appeal. (1) The finding of 
the treponema pallidum: This is done by placing a drop 
of serum taken from any lesion on a slide, and examining 
with the dark stage apparatus of a microscope. They 
may also be seen without the dark stage by mixing the 
serum with an equal amount of ink, and adding im- 
mersion oil when dry. The latter is not as reliable as 
the former. (2) Making a Wassermann test : If the case 
is one of syphilis the reaction will be positive in about 
90 per cent, of the cases. It usually does not appear 
until in the fifth or sixth week of the disease. A positive 
reaction indicates syphilis. A negative one is not absolute 
proof of the case not being syphilis. But if several tests 
are made at short intervals and they remain negative 
the case is almost surely not one of syphilis. The test 
is useful in all stages of the disease, and in latent syphilis. 
The taking of mercury may interfere with the positive 
reaction for a time, and when it is stopped for a time it 
may appear again. (3) The luetin test of Noguchi: 
This is a suspension of treponema pallida that has been 
grown in pure culture and then destroyed by beat. 
It is made by injecting into one arm T V c.c. of luetin 
and, at the same time into the other arm, an equal 
amount of the culture medium without the organisms. 
In a certain proportion of cases of syphilis the site of 
the first injection shows a reaction after a few hours in 
42 



658 DISEASES OF THE SKIN 

the form of an inflammatory nodule with or without a 
halo. It is at its height on the second or third day. 
It is not so reliable as the Wassermann test. 

One marked feature of the cutaneous lesions of syphilis 
is that they do not itch. Itching does occasionally occur 
with the scaling papular and crusted syphilides, when it 
is due to the irritation of the nerve ends by the crust or 
scale, and in some cases the patient will complain of an 
itching of the skin which is quite independent of syphilis, 
but in themselves they do not itch. 

The early eruptions of syphilis are general and exhibit 
a marked polymorphism, many different lesions being 
often present at the same time; as, for instance, macules, 
papules, and pustules. The late eruptions exhibit a 
strong tendency to grouping of the lesions in circles and 
segments of circles, and one characteristic of the circles is 
that they are seldom complete, but broken somewhere 
in their outline. 

The color of the lesions is peculiar, and perhaps may 
be best described as that of raw ham, though the classic 
term is "copper." This color is by no means always 
present. It is not seen in the early bloom of the early 
lesions, but is pretty sure to be found in those that have 
existed for some time, and in the late lesions. The color 
of a lesion on the legs, it must be remembered, must not 
be regarded for purposes of diagnosis; it is upon the 
arms, face, trunk, and thighs that we must look for the 
characteristic color. 

Painlessness is often a suggestive symptom pointing 
toward syphilis when we have to decide as to the nature 
of an ulceration. 

It is well not to lay too much stress upon the history 
of the case in making up our mind as to a late syphilide, 
because with the best intentions the patient may forget 
having had an insignificant initial lesion some twenty, or 
perhaps thirty, years before. 

Etiology. — Schaudinn, Hoffman, and many others have 
found spirocheta, or trepenoma pallida in syphilitic lesions. 



SYPHILIS 



059 



They are the only cause of the disease. The spirocheta 
pallida is a very slender thread closely wound in a cork 
screw shape, 7 to 21 microns long, with 8 to 20 spirals, 
and actively motile by rotation on its long axis in either 
direction without changing its position, or moving from 
place to place. Its ends are sharp. It has been found 
in the fluid expressed from syphilitic lesions, primary 
and secondary, both superficial and deep, congenital 
and acquired, and in smaller number in gummas. The 
chancre, mucous patch, and condyloma are specially 
rich in them. It also is found in the internal organs and 
the spinal fluid. It is always of pale color. 

Fig. 102 




Treponema pallidum. (Courtesy of Dr. Noguchi.) 



The disease occurs in all ages, even before birth. It 
may be acquired directly or secondarily. That it is not 
more often acquired from drinking glasses and the like is 
because its organism dies soon after exposure to the air. 
It is inoculable in apes. 

Pathology. — With the exception of the roseola whose 
pathology is that of any toxic erythema, all the various 
syphilitic lesions are histopathologically similar. The 
papule may be taken as the type of syphilitic cutaneous 
lesion, from which the other forms differ only in extent, 
severity, and secondary accidents. 

The papule is composed of a dense granulomatous 



660 DISEASES OF THE SKIN 

infiltration of the papillary layer of the corium, with 
small round cells, among which plasma cells are abundant 
and mast cells present in considerable number. The 
infiltration first follows the course of the bloodvessels, 
and appears to be secondary to an endarteritis and endo- 
phlebitis, though the latter is not so conspicuous as the 
arterial changes. New capillaries invade the infiltration 
and a moderate diapedesis from these gives to the gross 
lesion its characteristic raw ham color. The collagenous 
connective tissue bundles are increased in size and num- 
ber, and enclose in places groups of plasma cells which 
occasionally take on the form of giant cells. The infil- 
tration undergoes a fatty degeneration, or a coagulation 
necrosis due to the obliterating endarteritis, with subse- 
quent absorption or ulceration. There is never any 
attempt at organization into connective tissue. The 
overlying epithelium is affected only secondarily. m 

Hereditary Syphilis. — This differs from the acquired 
form in having no initial lesion, the disease being ac- 
quired in utero from either one or both parents. We 
cannot enter upon a discussion of the many connecting 
theories as to whether or not the child is diseased on 
account of springing from a diseased ovum, or sperma- 
tozoa; or the possibility of the disease, acquired by the 
mother after her pregnancy, reaching the fetus through 
the placental circulation; or like interesting questions 
over which the battle rages. For us now it suffices to 
make the bald statement that the disease may be acquired 
from one or both parents. It is most sure to be acquired 
from the motner, and it may be inherited by the fetus 
from a mother infected some months after conception. 
It is possible for a woman to show no signs herself of 
syphilis, and yet to give birth to a syphilitic child. It 
is exceedingly rare for the apparently healthy mother of 
a child hereditarily syphilitic to be infected by it. But 
a Wassermann test will show she is syphilitic though 
she may present no clinical evidence of the disease. As a 



SYPHILIS 661 

result of syphilitic infection in utero, the child may be 
born prematurely, and dead; it may be born at term, 
dead, and showing specific lesions; or it may be born 
alive with, some syphilitic eruption; or, as is commonly 
the case, the eruption may not appear before the second 
or third week. Miller, 1 from a study of 1000 cases of 
congenital syphilis in a foundling hospital in Moscow, 
found that the first appearance of the disease was in 
the first month of life in 64 per cent, of the cases; and in 
the second month in 22 per cent. In congenital syphilis 
there is a marked absence of that sequence of events 
more or less observed in acquired syphilis, but the diag- 
nosis is usually quite as easy. The earliest eruption 
to appear, as to point of time, is, according to Miller, the 
bullous syphilide, which he met with in 25 per cent, of 
the cases. One of the earliest and most characteristic 
symptoms of hereditary syphilis is "snuffles," due to an 
ozena, which gives the child great discomfort by inter- 
fering with breathing and nursing. 

The erythematous syphilide is, according to Taylor the 
most frequent and earliest eruption; according to Miller, 
it occurs in 45 per cent, of the cases. It begins on the 
lower part of the abdomen as minute round or oval 
spots, that disappear under pressure at first. It invades 
the whole body within a week, when the lesions will no 
longer fade under pressure, but assume the characteristic 
syphilitic color. One form of the erythematous syphilide 
in children is seen upon the inside of the thighs, about 
the anus, and on the buttocks, and may extend down to 
the feet. It is patchy in character, the patches being 
either of small size, or large by the coalescence of several 
smaller ones. It differs from intertrigo in its patchy 
character, in its darker color, and in its wider distribu- 
tion. 

The papular syphilide and its modified forms of the 
mucous patch and condylomata lata are common congeni- 

1 Jahrb. der Kinkerheilkunde, 1888, xxvii, Heft 4. 



662 DISEASES OF THE SKIN 

tal lesions. The lenticular syphilide, large and small, is 
met with far more frequently than the miliary papular 
syphilide. It is usually a symmetrical and general erup- 
tion. It may be smooth or scaly, and always has the 
raw ham color. Mucous patches are very often at the 
junction of the mucous membrane and the skin, as on the 
lips or anal orifice. The movements of the parts will 
give rise to painful fissures — rhagades — which constitute 
a sign of hereditary syphilis as characteristic as the 
" snuffles." These rhagades Miller met with in 70 per 
cent, of his cases. Mucous patches also occur in the 
cavity of the mouth. Condylomata lata occur where two 
skin surfaces rub together, and especially where there is 
more or less moisture, as about the anus and genitals, in 
the groins and axilla?, and between the fingers and toes. 
Their color is usually grayish pink to dark brown; their 
size varies greatly, and their surface is flat, or fissured 
and ulcerated, and exudes an offensive secretion. They 
are characteristically located when at the angles of the 
mouth, in combination with mucous patches in the mouth 
with rhagades between. 

The pustular syphilide may be general, but is usually 
most pronounced on the thighs, buttocks, and face. It 
shows a tendency to group about the mouth. It is usually 
indicative of profound syphilization. The pustules may 
leave scars. Ecthymatous pustules may develop, but 
usually not till late in the disease. 

The vesicular syphilide is a rare form of early con- 
genital syphilis of severe type. It is never general, but 
appears as groups of closely packed together vesicles upon 
the chin, about the mouth, or on the nates, forearms, 
hypogastrium, or thighs. They are seated upon infil- 
trated, brownish-red bases. The larger vesicles may be 
seated upon papules. This eruption is apt to be asso- 
ciated with a pustular or bullous syphilide. 

The bullous syphilide, unlike what obtains in adults, is 
comparatively common in congenital infantile syphilis. 
Miller found it in 25 per cent, of his cases. It frequently 



SYPHILIS 



663 



exists at birth or as the earliest syphilide, and is indicative 

of a severe form. It is most commonly seen on the palms 

and soles, which are often covered with the lesions, 

while few, if any, are on the trunk. The face is a favorite 

location for the eruption. The bullae are either tense or 

flaccid, and at first have seropurulent contents that soon 

become purulent. They are seated upon a raw ham 

colored infiltrated base. Hemorrhage into them not 

infrequently occurs. When they rupture or dry up they 

exhibit an unhealthy-looking 

ulceration that soon becomes 

covered with a greenish crust. 

Some of them may dry up 

with little, if any, ulceration. 

It rarely relapses. It differs 

from pemphigus in occurring 

upon the palms and soles, 

while sparing the trunk, and 

in the profound cachexia and 

the presence of other signs of 

syphilis. 

The tubercular syphilide is 
not common, and is always a 
late lesion. While it may be 
seen as early as the sixth 

month, it is more apt to occur much later as a relapsing 
syphilide. In appearance and course it resembles the 
same lesion of acquired syphilis. 

The gummatous syphilide is also a late manifestation 
of the disease, and is sometimes met with in early adult 
life as a lesion of congenital syphilis. 

Kaposi regards as a special and characteristic symptom 
of hereditary syphilis a diffused infiltration of the palms 
and soles, the skin of which is uniformly brownish red, 
dry, shiny, and fissured. 

Besides the skin-lesions the infant bears certain unmis- 
takable signs of syphilis. It has a marked pallor, and, 
no matter how blooming it may appear at first, it soon 




Hutchinson's teeth. 



664 DISEASES OF THE SKIN 

loses flesh and assumes "an old man" countenance. It 
has a characteristic, hoarse, toneless cry, which once heard 
will be remembered. Its hair is scanty, its nose is apt 
to be flattened, and altogether it is a most woeful- 
looking object. The skin eruptions usually occur within 
the first six months of life, and if the child can be brought / 
through that period it may suffer no more. Nevertheless 
congenital syphilis, like the acquired disease, may be 
latent for years, to crop out once more. The victims 
of congenital syphilis, sometimes show the notched or 
peg-shaped teeth, regarded by Hutchinson as a certain 
sign of the disease (Fig. 103). This appearance is pre- 
sented by the second set of teeth only, and is not abso- 

Fig. 104 




Dactylitis. (After Bergh.) 

lutely diagnostic, as the same has been met with in 
scrofula. The two middle upper incisors are those which 
are depended on for diagnosis. "They are small, often 
converging, sometimes diverging. The cutting-edge of 
the teeth is sometimes narrowed, rounded off. They are 
stunted and badly developed, often marked with seams 
in front, and of a dirty brownish color, but their chief 
peculiarity is found in their edges, which, being thin 
when cut, break off centrally, leaving a broad, shallow, 
vertical notch on the lower border of the tooth" (Keyes). 
The syphilitic child is subject to diseases of the bones, 
one of the most characteristic of which is dactylitis. 
Another characteristic is the prominent bosses on the 



SYPHILIS 665 

forehead. Space will not permit of a detailed description 
of the bone and other lesions apart from those of the skin. 

Treatment. — The treatment of syphilis is by the use 
of both constitutional and local remedies, and by a con- 
stant and long-continued watchfulness on the part of the 
physician over the patient's hygiene and general well- 
being. One chief obstacle to the successful treatment of 
a case is the patient's lack of faith in his physician. Most 
patients, just as soon as the eruption for which they sought 
advice fades away, will cease coming to the physician, 
and will pay little heed to his warning, that unless they 
keep themselves under medical supervision for three or 
four years they will be liable to serious trouble later on. 
Nevertheless, our first duty is to so instruct them. Then, 
before putting the patient upon a regular course of treat- 
ment, we should give him careful directions as to his 
exercise, liberal diet, and bathing, and should stop his 
alcohol, insist upon his taking plenty of sleep, and giving 
up the use of tobacco. This last is not only to put him 
in better condition, but also to prevent mucous patches in 
the mouth. It must never be forgotten that there is no 
use in giving medicine to a dead man, and that while a 
patient is taking antisyphilitic treatment every means 
should be taken to keep him in the best possible physical 
condition. Very often a patient who is not making 
satisfactory progress will immediately improve when he 
is given a change of air and general tonics. The patient 
should be cautioned against drinking out of public 
drinking-cups, and apprised of the danger of infecting 
others by means of table utensils, pipes and the like. 
Now he is ready for his course of treatment. 

Constitutional Treatment. — Treatment should be begun 
as soon as we are sure that the patient has syphilis. 
As the treponema pallida is usually readily found in the 
initial lesion and is positive proof of syphilitic infection, 
treatment should be begun as soon as it is found with- 
out waiting for the appearance of a secondary eruption 
as used to be advised. 



666 DISEASES OF THE SKIN 

We will consider first the treatment of early syphilis 
and the use of mercury. This drug, regarded by the 
majority of physicians as the sheet-anchor in the treat- 
ment of syphilis, is administered, for its constitutional 
effect, by the mouth, by inunction, by fumigation and by 
hypodermic injection. 

Of these different methods, the most frequently em- 
ployed is the first — that is, by the mouth. This is the 
most convenient and the most unreliable method, and 
should not be used if it is possible to give the drug by 
inunctions or intramuscularly. The salt of mercury 
most frequently used is the protiodide, otherwise called 
the green iodide. This may be exhibited either in pill, 
tablet triturate, or granule, the tablet triturate being the 
preferable form. The objection raised by many authori- 
ties to the use of the protiodide, namely, its irritant 
effect on the intestinal tract, is its shining virtue, because 
instead of giving warning of intoxication by causing 
salivation, it does so by causing colicky pains and diar- 
rhea. The dose to begin with should be from \ to J of a 
grain three times a day after meals, and the number 
of pills increased by one every third or fourth day until 
there is a little " colicky diarrhea." The dosage should 
be then continued at the same number of pills, until the 
symptoms are controlled. Then we can reduce it to 
half the number. It may be necessary, to give a little 
opium at the same time with the mercury, in order 
to control the diarrhea if it is deemed advisable to con- 
tinue the drug at the point of full tolerance, and this not 
only with the protiodide, but with other salts. Practically 
the daily dose of the protiodide may be put at 4 or 5 of 
the \ grain tablets, and 3 or 4 of the \ grain ones, and 
opium is rarely called for. 

Many prefer to use metallic mercury in the form of 
hydrargyrum cum creta, or calomel in the dose of 1 or 
2 grains two or three times a day after meals, increased 
every three or four days sufficiently to influence the erup- 
tion. Salivation is, in the general run of cases, to be 



SYPHILIS 667 

avoided. Some authorities prefer to combine a tonic with 
the mercury. Taylor gives the following : 

.45-.58 
39 M. 



Ft. 


-Hydrarg. protiodid., 
Ferri et quininse citrate., 
Ext. hyoscyami, 
pil. No. xxx. 


gr. vij-ix 
3iss 
gr. vj 


Ft. 


-Hydrarg. tannici, 
Quin. sulphat., 
Ext. hyoscyami, 
pil. No. xxx. 


gr. xv-xxx 

3J 
gr. vj 



1-2 
4 



39 M. 



In severe cases in which it is necessary to get the 
patient rapidly under the influence of mercury, calomel 
in Yj- grain doses in the form of tablet triturates may 
be given every hour until the gums become tender. 
Then the calomel should be stopped and the treatment 
continued with small doses of the protiodide. 

Besides these preparations of mercury we may use the 
bichloride in doses of ■$% to j-% of a grain in solution. It 
is usually given in compound syrup of sarsaparilla or some 
bitter infusion. The most common mode of administer- 
ing it is in combination with the iodide of potassium, the 
so-called mixed treatment, the formula for which will be 
given later when speaking of the treatment of late 
syphilis. The best opinion is in favor of reserving the 
use of iodine until the early stage is passed. The tan- 
nate of mercury is well spoken of in the dose of half a 
grain. Space will not allow of mentioning the other salts 
of mercury that have been recommended. 

The proper quantity for administration having been 
learned by experiment, the drug should be administered 
continuously for from four to six months. 

Where practicable the use of mercury by inunction is 
the speediest and best way of getting the patient under 
the influence of the drug. It may be used from the first 
or at any time during the course of the disease. Its great 
advantages are the promptness with which it acts and the 
sparing of the stomach and intestinal tract. Its great 
disadvantages are that it is a dirty method, impracticable 
with most patients, as it attracts notice from friends 



668 DISEASES OF THE SKIN 

and attendants; and the difficulty encountered in getting 
the patient to carry out the treatment with thoroughness. 
It is admirable for hospital treatment. The patient is to 
be told to rub into his skin, once a day, a piece of ungt. 
hydrarg. cinereum, or an ointment made with lanolin as a 
base, of the size of a hazel-nut — from \ drachm to 1 
drachm (2-4). He is to divide the mass into two equal 
parts, and work it into his skin with the heel of his hand for 
about fifteen minutes while he sits before a fire or in a warm 
room. Before beginning the inunctions he is to take a warm 
bath, and to bathe the parts about to be rubbed with 
alcohol so as to open the pores of the skin and to remove 
any sebaceous matter. The first day he is to rub the 
ointment into the bends of both elbows; the second day, 
over the sides of the chest; the third day, over the abdo- 
men; the fourth day, on the inside of the thighs; and the 
fifth day, behind the knees — that is, he is to choose the 
parts least covered with hair; and to change the sites of 
the inunctions, so as to avoid setting up a mercurial 
dermatitis. On the sixth day he is to take another bath, 
and on the seventh day to resume the inunctions. The 
treatment is to be pursued until active symptoms of the 
disease are overcome, when all treatment may be sus- 
pended. A thorough course of from eighty to a hundred 
inunctions is said to be often followed by a permanent 
cure. If the inunctions are to be made by an attendant, 
he should wear a stout rubber or leather glove. 

As a substitute for inunctions, E. Welander 1 proposes 
spreading about 1| drachms (6) of mercurial ointment on 
the inside of a small pillow-case ticking, and having the 
patient wear this, properly fastened, next the skin over 
the anterior plane of the body, day and night. Kro- 
mayer 2 advises the use of a mask made of a light wire 
frame covered with several layers of muslin impregnated 
with a thin layer of mercurial ointment. It is made to 
fit over the nose and chin and worn at night, bandages 

1 Arch, f . Dermat. u. Syph., 1897, xl, 257. 

2 Monatshft. f. prakt. Dermat., 1908, xlvi, 475. 



SYPHILIS 669 

being used to hold it in place. After five nights' use the 
mask is to be reversed and used for B.ve nights more. At 
first it may cause disturbed sleep, and dizziness in the 
morning. He has found it more active than inunctions 
but not so active as injections. Mercuriol may be sub- 
stituted for the usual mercurial ointment. These plans 
of treatment are good only in slight cases. 

Fumigation is a method which is not used as much now 
as formerly. It requires the use of a special apparatus and 
a great amount of time and trouble. It is said to be a very 
efficient method, especially useful in bad cases and where 
prompt results must be attained. From \ to 1 drachm 
(2-4) of calomel, metallic mercury, or other salt of mer- 
cury, is vaporized by means of the special apparatus, the 
naked patient sitting over it enclosed in a cabinet or 
blankets, out of which only his head protrudes. Each 
bath lasts ten minutes, and it is repeated every second day. 

The intramuscular injection method of administering 
mercury, was first advocated by Scarenzio in 1854. It 
is quite as efficient as inunctions, perhaps a little more so. 
It is cleaner than the latter. The injections are usually 
made deep down in the gluteal region, behind and above 
the great trochanter. Its disadvantages are that the 
injections are usually painful; sometimes are followed by 
emboli and abscesses, and require daily or frequent 
visits to the physician's office. They are useful where 
we wish to have a very prompt effect from the mercury, 
as in a malignant precocious case of syphilis; or where 
the stomach must be spared; or where the disease has 
not yielded to the ordinary plans of treatment. Great 
care must be given to the sterilization of the needle 
and of the skin. A great number of salts of mercury and 
combinations have been introduced, each one of which has 
been found by its producer the best and most reliable. 
An admirable study of them will be found in Hare's Sys- 
tem of Therapeutics, vol. ii, by Prof. R. W. Taylor. Here 
we can indicate, and briefly, but a few. Taylor gives one 
of corrosive sublimate, gr. xl (2.33); glycerin, 5j (4); dis- 



670 DISEASES OF THE SKIN 

tilled water, 3hj (12), of which 12 drops are used at each 
injection. The albuminate of mercury, dose 15 minims: 
the formamide (Liebreich), dose \ to a whole Pravaz 
syringeful of a 1 per cent, solution: calomel, 1 part, to 
liquid vaselin, 12 parts, dose \ Pravaz syringeful once 
a week; "gray oil," composed of 20 parts of pure 
mercury, 40 of liquid vaselin, and 5 of ethereal tincture 
of benzoin, dose J of a syringeful every ninth day; 1 the 
salicylate, 22J (1.5) grains in lanolin 15 grains (1) and 
benzoinal ad §ss (16). Dose | to 1 syringeful. And 
many others. As a rule the soluble salts solutions are 
injected once every day or so, and the insoluble ones 
once a week. A final judgment as to the comparative 
merits of the many salts cannot yet be given. 

Dr. John A. Fordyce has kindly advised me in regard 
to the use of salvarsan as follows: 

The arsenical preparation, salvarsan, is the most 
efficient drug at present in use to combat the syphilitic 
infection. Given in the primary stage the disease may be 
aborted, the Wassermann reaction remaining persistently 
negative, and no further clinical symptoms manifesting 
themselves. When the secondary contagious lesions 
are present it has a much more rapid effect than any 
other drug in limiting the time during which the patient 
is a menace to his surroundings. In the later period of 
the infection when combined with mercury it has a 
much more marked influence over the Wassermann 
reaction than mercury alone. In malignant syphilis 
there is no remedy known which has such a marvelous 
influence on the symptoms. In cases which are resistant 
to mercury or where mercury has been administered for 
a long period of years with repeated relapses and with 
persistence of a positive Wassermann reaction salvarsan 
is the drug above all others to control the manifestations. 

Salvarsan is a light yellow powder put up in her- 
metically sealed ampoules in doses varying from 0.1 gm. 

1 Leloir and Tavernier: Giorn. Ital. d. Mai. Ven. e del Pelle, 1889, 
xxiv, 247. 



SYPHILIS 671 

to 1 gm. Its active principle is arsenic of which nearly 
3 grains by weight or the equivalent is nearly 4 grains 
of arsenous acid occurs in a dose of 0.6 gm. While 
its preparation and administration to the initiated are 
simple, in the hands of the inexperienced undesirable 
results may follow, and it is therefore incumbent upon 
everyone attempting to treat syphilis to familiarize him- 
self with the proper technique. 

In the preparation of the drug for injecting the follow- 
ing precautions are to be accentuated: (1) The water em- 
ployed for its solution should be distilled on the day of 
use, as old distilled water contains organisms or their 
products which give rise to reactions. (2) The saline 
solution should also be made from freshly distilled water 
and the salt should be chemically pure. (3) The sodium 
hydroxide solution should be fresh and free from pre- 
cipitate. (4) All the apparatus used in connection 
with the preparation and administration should be 
sterile. (5) Each ampoule before opening should be 
tested for cracks, by placing in alcohol, and if any are 
present or the tube has been opened for some time it 
should be discarded, as salvarsan oxidizes on exposure 
and becomes toxic. 

Xeosaharsan, a later preparation than salvarsan, is 
a slightly darker powder and one-half heavier, 0.9 gm. of 
the former being equal to 0.6 gm. of the latter. It is a 
neutral, extremely soluble salt, its chief advantage being 
simplicity of preparation. As it oxidizes very rapidly, 
forming a poisonous compound, in making the solution 
shaking is to be avoided and it must be used immediately 
For intravenous use it is diluted in sterile distilled water 
at room temperature in the proportion of 0.9 gm. to 100 c.c. 
It is not as safe as salvarsan. 

Methods of Administration. — The intravenous mode 
of administration by the gravity method is the one of 
choice. If, however, the proper technique cannot be 
carried out it is advisable to give the drug intramuscularly. 
For intravenous use the amount of fluid employed in 



672 DISEASES OF THE SKIN 

the case of salvarsan is in the proportion of 0.1 gm. to 
30 c.c. The procedure is as follows: Pour into a glass 
stoppered graduated cylinder 60 c.c. of hot freshly 
distilled water. Drop the contents of a 0.6 gm. ampoule 
on the water and shake vigorously until every particle is in 
solution. Next add drop by drop a 15 per cent, caustic 
soda solution until the resulting precipitate is again 
redissolved. To this end 15 to 19 drops are required. 
The solution must be perfectly clear, but over-alkaliniza- 
tion should be avoided as thrombosis of the vein is apt 
to occur. The dilution is then made to 180 c.c. with 
0.5 per cent, saline solution. 

For intramuscular injections an oily suspension may 
be made of salvarsan or neosalvarsan in sterile glycerin, 
liquid paraffin or iodiopin. The powder is placed in a 
sterile mortar and rubbed with 1 c.c. of the vehicle, 
more being gradually added until the suspension reaches, 
a volume of 2 to 4 c.c. Salvarsan may also be given in 
alkaline solution, but this is usually very painful. The 
powder is dissolved in 10 c.c. of hot distilled water and 
enough caustic soda solution added to give a clear solution. 
It is then diluted to 20 c.c, 10 c.c. being injected into 
each buttock. 

Preparation of the Patient. — The patient should have 
a physical examination to determine the condition of 
his heart and kidneys. If there are no contraindications 
he should take a laxative the night before and abstain 
from all food for at least three hours before its adminis- 
tration. For the intravenous injection he should lie 
on his back. A tourniquet is placed about the upper 
arm to distend the veins in the cubital space and one of 
these is usually chosen. If it cannot be seen it can often 
be felt under the finger and failing this, in the case of fat 
people, or women with small veins, one may be selected 
in the wrist or back of the hand or even the ankle or 
foot. It is never necessary to cut down on a vein as 
search will always disclose one somewhere on the upper 
or lower extremities accessible to an operator with 



SYPHILIS 673 

technical ability. The skin is sterilized, and as soon as the 
needle is in the vein and the blood flows back the tourni- 
quet is released, the clamp on the tubing is loosened, and 
the fluid allowed to run in slowly. When the desired 
amount has been given the needle is quickly removed 
and a small dressing applied. If the needle fails to pene- 
trate into the lumen of the vein, when first inserted the 
fluid infiltrates the surrounding tissues causing severe 
pain. It should then be quickly withdrawn and the fluid 
expressed through the puncture. The patient should be 
on a very light diet and rest in bed until the follow- 
ing day. This should be insisted upon as unpleasant 
symptoms like headache, nausea, or gastro-intestinal 
disturbances may intervene if these directions are not 
carried out. 

For the intramuscular injection the patient lies on his 
abdomen. The skin on the buttocks is disinfected and 
the injection given deep into the gluteal muscles. The 
areas are well massaged. 

Dosage. — In order to avoid the toxic effect of salvarsan 
it is advisable to give small initial doses until the toler- 
ance of the patient is determined and then the dose may 
be gradually increased. The average dose for an adult 
man is from 0.3 gm. to 0.45 gm. and for women from 
0.25 to 0.35. The advantage of these medium sized doses 
is that they can be repeated at shorter intervals and 
kept up for a longer time than when the maximum dose 
is given. In early syphilis a few doses of mercury intra- 
muscularly should precede the systematic use of salvarsan. 
The best results are obtained by giving it in series of 
from four to six intravenous injections at intervals of 
about ten days combining it with intramuscular injections 
of mercury, continuing with eight or ten of the latter 
after the salvarsan series. At the end of this course of 
treatment a month's interval should elapse and the 
series of salvarsan and mercury injections repeated. 
Two or more such courses may be necessary in order 
to influence the Wassermann reaction in early syphilis. 
43 



674 DISEASES OF THE SKIN 

In late syphilis and in hereditary forms of the disease 
even several series may fail to change the reaction. 

Suggested by the success of salvarsan many other 
arsenical preparations have been brought out, but none 
has shown itself the equal of salvarsan. Of these contra- 
leusin, a combination of salicylic acid, sozojodal, quinin, 
and bichloride of mercury, has met with some favor. The 
dose is 1.5 cc, which is given with a glass syringe. The 
injections are given intramuscularly in the buttocks. It 
is repeated in five days. After four injections are given, 
a pause of from one to four months is made, and then the 
series repeated. 

Late Syphilis. — The treatment of the later manifesta- 
tion of syphilis is the same as the earlier ones — by the 
use of salvarsan and mercury. The former will cause a 
prompt disappearance of the ulcerative and other lesions 
of the skin and tongue. If for any reason salvarsan 
cannot be used then the so-called mixed treatment will 
be most appropriate to the case. As usually administered 
it is made up according to one of the following formulas: 

T$— Hydrarg. bichlor. vel, 06-12 

Hydrarg. biniodidi, aa, gr. j-ij 

Potass, iodidi, 3J~iJ 4-8 

Inf. gentian, co. vel, 

Syr. sarsaparillae co., aa ad §iv ad 120 M. 

Dose: A teaspoonful three times a day after meals. 

Or, 



1$ — Hydrarg. biniodidi, 






gr. ss-ij 






03-1 


Ammon. iodidi, 






3ss 




2 




Potass, iodidi, 






3ij-5j 




8-32 




Syr. aurant. cort., 






Biss 




45 




Tr. aurant. cort., 






5i 




4 




Aqua?, p. 


s. 


ad 


5"j 


ad 


100 


M 


Dose: A teaspoonful in 


water 


three times a 


day. 


(Key< 


ss.) 



If any deep lesions threatening destruction of tissue 
appear early in a case of precocious or malignant syphilis ; 
or if the disease attacks the nervous system, the larynx, 
pharynx, or eye — in fact, at any time when there is 
need of prompt effects and for any reason salvarsan 
cannot be used, we must administer the iodides. If the 
patient has had no mercury for some time, it is best to give 



SYPHILIS 675 

it to him now either by the mouth, injections, or inunc- 
tions, while the iodide is administered separately but at 
the same time. The iodide of potassium is most generally 
used, and next to it the iodide of sodium. There is no 
set dose for the iodide. It is best given in a dose of 5 
grains (0.33) in solution in water, three times a day, before 
meals, diluted in milk, or Vichy, or soda water; or some 
three hours after meals. Delavan 1 has found that the 
iodide can be given most satisfactorily by putting 5 
drops of a saturated solution in the bottom of a small 
tumbler, with 15 drops of essence of pepsin, and pouring 
upon it 2 ounces (64) of warm milk. This is to be set away 
in a cool place, and will form a rennet custard, which can 
be easily swallowed. This is a good method when we wish 
to give nourishment with the medicine or when the throat 
is sore. The mixture can be given a pleasant taste by 
adding a teaspoonful of sherry wine. 

The dose of the iodide should be increased by 1 or 2 
drops each day — that is, 6 drops t. i. d.; then 7 drops 
t. i. d., and so on, until the nose runs and the eyes water, 
or some symptom of iodism develops. The most con- 
venient method of administration is to have a solution 
made containing 1 grain of the iodide to each drop of 
the solution, so that every drop represents a grain. Most 
patients bear iodine well, but in some even drop doses 
produce iodism. Iodic acne is very often induced, but 
should not cause us to stop using the drug. It is advis- 
able to suspend the administration of the iodides from 
time to time, and to give mercury, which, after all, must 
be depended on for curing syphilis. 

Now and again we will meet with cases that do not 
improve under either mercury or iodine, but relapse and 
relapse, or remain stationary. Such cases should be sent 
out of town, ordered change of air for a time, and put on 
a purely tonic course of treatment. Very often when 
the patient returns home he can take his medication 

1 Med. Rec, 1891, xl, 651. 



676 DISEASES OF THE SKIN 

easily, and the previously obstinate lesions will yield 
readily. This is but what we said at first: the patient's 
general condition must all the time be carefully watched 
over. 

Salivation is an unpleasant accident that may occur 
under the use of either mercury or iodine. At one time 
it was quite common — indeed, mercury was purposely 
pushed so far as "to touch the gums," and, of course, this 
was often overdone. Its symptoms are tenderness of the 
teeth, so that pain is felt when the jaws are snapped to- 
gether; the gums are swollen; there is a metallic taste 
in the mouth; a fetid odor of the breath; increased flow 
of saliva by day and night; all the mucous membranes 
of the mouth are swollen, so much so as to interfere 
with mastication and deglutition, and in very bad cases 
there may be ulceration, loosening and fall of the teeth, 
and caries of the bones. 

Prevention is always better than cure, and to this end 
we should see that our patient's teeth are in good order 
before beginning treatment, and direct him to wash his 
mouth frequently with chlorate of potash solution, 10 or 
15 grains to the ounce, or one of alum, and to keep his 
teeth clean. The patient should be seen frequently at 
first, so as to stop the mercury before salivation attains 
any serious degree. Salivation having begun, the mer- 
cury must be stopped, and the potash solution in same 
strength may be continued, and 1 or 2 drachms (4 to 8) 
of it swallowed during the day. The compressed tablets 
are useful. Dilute Labarraque's solution, or solutions of 
permanganate of potash or other astringent, may be used 
for a gargle and mouth-wash. A laxative should be admin- 
istered, the patient kept warm in bed, and, if necessary, 
an anodyne given. 

Until Wassermann gave us his serum reaction test 
it used to be a question how long treatment should be 
continued. Now we know that the disease is not cured 
as long as the test remains positive. Treatment must 
be continued until a negative reaction is obtained, and 



SYPHILIS 677 

after that the patient's blood must be tested for two or 
three years at least. If the test is still negative at the 
end of that time the disease may be considered cured. 

Local Treatment.— While internal treatment by 
salvarsan and mercury is quite competent to remove 
the syphilides, their disappearance can be materially 
hastened by local treatment by means of mercurial 
applications. Ointments of metallic mercury, of the 
ammoniate, the red oxide, and the oleate, with solutions 
of the bichlorides, are the preparations most generally 
employed. 

Many attempts have been made to abort syphilis by 
excision of the initial lesion, or its destruction by means 
of caustics. These have been failures in most instances. 
This is not to be wondered at in the light of R. W. 
Taylor's studies, 1 which show that "in the very first 
days of syphilitic infection the poison is deeply rooted 
beneath the initial lesion, and extends far beyond it, 
infecting all the parts beyond even to the root of the 
penis." The initial lesion should be dressed with iodoform 
or calomel, or kept covered with dry lint powdered with 
either of these. 

It may be said that in all the early and generalized 
syphilides local treatment needs practically to be applied 
only to lesions on exposed parts — that is, face, neck, hands, 
and wrists. The erythematous syphilide is usually so 
ephemeral that no local treatment is necessary. Mer- 
curial baths may, however, be used for general outbreaks 
of syphilis. If the erythematous lesions persist upon the 
exposed parts, their departure can be hastened by the use 
of the ointment of the ammoniate of mercury rubbed in 
morning and night. The same ointment may be applied 
to the papular syphilide. A still more prompt effect can 
be produced, if the patient can be seen often enough, by 
the physician touching each lesion with a solution of the 
bichloride of mercury in alcohol 3 to 5 grains (0.18 to 0.33) 

1 Med. Rec, 1881, xl, 1. 



678 DISEASES OF THE SKIN 

to the ounce (32), according to the size of the lesions and 
the profuseness of the eruption. Of course, if the eruption 
is very profuse, this plan cannot be followed. It is most 
applicable to a sparse and relapsing eruption. 

The mucous patch should be touched with the nitrate 
of silver stick or with an aqueous solution of chromic 
acid, 10 grains (0.66) to the ounce (32). Condylomata 
are best treated with dusting powders, preferably calomel, 
freely applied and covered with absorbent cotton. 

The squamous syphilide of the palms and soles is often 
obstinate, but will usually yield to the persistent use of 
mercurial ointment. Sometimes it will be necessary to 
soften the part by having the patient wear sheet rubber 
next the skin for several days, and then use the ointment. 
If the parts are covered with a very much thickened 
epidermis, we may have to remove this by using salicylic 
acid, as in chronic squamous eczema. Mercurial plaster 
worn continuously is efficient. 

The tubercular syphilide occurring discretely can be 
touched with the bichloride solution already mentioned. 
When in groups it is best treated by means of mercurial 
plaster. 

The gumma may be covered with mercurial plaster or 
ointment. It should not be incised unless it shows unmis- 
takable evidences of containing pus. 

Ulcers following whatever lesion may be covered with 
mercurial plaster or ointment, or dressed with iodoform 
or aristol. If they become sluggish, they may require 
stimulation, just as a simple ulcer does. To this end we 
may touch them with balsam of Peru, or add the same to 
our mercurial ointment. Some ulcers will do best under 
the treatment applicable to a simple ulcer, while the iodide 
of potassium is pushed. 

Treatment of Congenital Infantile Syphilis.— 
The most popular method is to spread upon pieces of 
flannel a mass of mercurial ointment of about the size of 
the end of the finger, and tie a piece of this one day over 
each elbow-joint; another day over each groin; another, 



SYPHILIS 679 

under each knee; and another, over the abdomen, allow- 
ing the movements of the child to work the ointment into 
the skin. Or hydrarg. cum creta, 1 grain three times a 
day, may be given by the mouth. Monti 1 recommends 
the following: 

I 1 

I 2 
3| M. 



1$ — Calomel, pur., 


gr. iss 


Ferri lactatis, 


gr. iij 


Sacch. alb., 


gr. xlv 


Ft. in pulv. No. x. 




Sig. 1 to 4 powders daily. 





The greatest attention must be given to the hygiene of 
the child and to its diet. Cod-liver oil should be given 
along with the mercurial. The nose must be kept clear, 
and if this is not practicalbe the child must be fed with a 
spoon. After the disappearance of symptoms tonics should 
be given, one of the best being the syrup of the iodide of 
iron. In all other respects the treatment of infantile 
syphilis is the same as that of the acquired form. Kaposi 
commends the tannate of mercury for children; dose, \ 
to f of a grain three times a day. 

Prognosis. — The prognosis of syphilis as seen at the 
present time and in this country may be said to be good. 
Many cases go no further than a general erythematous or 
papular eruption, even when untreated. In one of robust 
health the disease is usually readily manageable. In 
debilitated subjects it sometimes proves intractable. The 
worst feature of the disease is the great uncertainty of its 
course, no one being able to promise confidently, no 
matter with what treatment, that relapses and late 
visceral syphilis will not occur. Since the introduction 
of the combined salvarsan and mercury treatment the 
number of reinfections has greatly increased. This shows 
that the disease is curable. The continuance of the 
negative Wassermann tests also attests its cure. 

The prognosis of congenital syphilis is not as good as 
is that of the disease as it affects adults. Many, perhaps 
most, of the cases seen in public institutions die. In pri- 

1 Arch. f. Kinderheilku de, 1885, vi., 1. 



680 DISEASES OF THE SKIN 

vate practice more can be done, and we should always 
count upon the remarkable reparative powers of childhood 
in making our prognosis. A great deal will depend upon 
the inborn vigor of the child. 

Syringomyelia, or Morvan's Disease, is a disease of the 
spinal cord, the consideration of which belongs rather to 
the neurologist than the dermatologist. It interests us 
because various cutaneous lesions occur during its course, 
such as glossy skin, hyperkeratosis, hyperidrosis, and 
paronychia with necrosis of the phalanges; and because 
in some phases it resembles certain stages of leprosy. 

Tattoo.- — These well-known stainings of the skin by 
means of India-ink, vermilion, charcoal, and gunpowder, 
although at first objects of pride to the boy or girl, later 
are apt to become objects of aversion. They are very 
difficult to remove, especially if they are at all extensive. 

Fig. 105 



<Q '/4 OF REAL SIZE. 

Keyes's punch. 

Patient perseverance in going over and over the small 
ones, that cannot be excised, with the electrolytic needle 
will sometimes greatly lessen them, though, of course, we 
thereby substitute a white cicatricial spot for a colored 
one. The needle should be introduced perpendicularly to 
the skin and deeply, and numerous punctures arranged 
in rows thus made. This, of course, is a very slow pro- 
cedure Powder-grains may be removed by Keyes's 
punch, by making a half-turn over them, and then 
snipping off the small piece with the scissors (Fig. 105). 
Ohmann-Dumesnil 1 recommends thrusting into the 
stain a bunch of 6 to 10 very fine cambric needles, tied 

1 New York Med. Jour., 1893, lvii, 544. 



TELANGIECTASIS 681 

tightly together with silk thread, after dipping them into 
the glycerole of papoid. This is composed of: 



R— Papoid, 


gr. ij 


23 


Aquae destil., 


3J 


4 


Glycerin, pur., 


3 iij 


12 


Ac. hydrochlor. dil., 


gtt, iij 


gtt. iij M 



If required, anesthesia may be obtained by the ethyl 
chloride spray. The needles are to go deep enough to 
bring a few drops of blood to the surface. After punc- 
turing, pour over the surface some of the solution and 
cover with antiseptic gauze. Remove this after two or 
three days. In this way the whole tattoo-mark is to be 
gone over. The process may have to be repeated. 

J. Brault 1 recommends tattooing the marks with a 
solution of 30 parts of chloride of zinc and 40 parts of 
sterilized water. The superficial eschar falls in Hve or 
ten days. The process may have to be repeated several 
times. Variot 2 first covers the part with a concentrated 
solution of tannin which he tattoos into the skin, the 
punctures being made close together. Then he passes a 
stick of nitrate of silver over the part, allows it to re- 
main for a few minutes, and then washes it off. A black 
crust forms that falls in a few weeks leaving a scarcely 
perceptible scar. 

Dubreuilh 3 recommends shaving off a fine layer of the 
skin, or a second layer if this does not remove the mark. 
The wound is to be dressed with dry gauze and a snug 
bandage, and allowed to come off when cicatrization is 
complete. If the mark is very deep it is well to use 
skin grafts before dressing with the gauze. 

Telangiectasis. — This is an acquired, permanent dilata- 
tion of the capillaries of the skin. 

Symptoms. — The most common form of the disease is 
nevus araneus, or what is vulgarly called " spider cancer." 
It occurs in nearly all cases upon the cheeks, near the 

1 Annal. de derm, et de syph., 1895, vi, 33. 

2 Compt. Rend. Soc. Biol., 1888, p. 636. 

3 Annal. derm, et syph., 1909, x, 367. 



682 DISEASES OF THE SKIN 

eyelids or bridge of the nose, but may occur anywhere. 
It is usually a single lesion, and consists in a small, 
central, bright-red, slightly raised dot from which radiate 
fine red lines. They sometimes become quite large, 
though usually not more than a half-inch in diameter. 
This form is seen in women and children. It occasion- 
ally follows some slight injury, but very often seems 
to come spontaneously. There may be a great number 
scattered over the face the skin of which is thinned. 

Telangiectases in the form of simple dilated blood- 
vessels of varying size and shape are often seen. Under 
the same heading Crocker places those slightly convex or 
flat, hemp-seed-sized, raised, bright-crimson or purplish 
spots met with in old people. Their favorite site is the 
upper part of the trunk, neck, and face. 

Etiology. — Telangiectases sometimes are the result of 
some slight injury, as the prick of a pin or a mosquito- 
bite. Sometimes they are due to continued congestion 
of the skin from disease of the internal organs, such as the 
liver. In other cases they result from a chronic inflam- 
matory disease of the skin. They are very common upon 
the trunk in advanced life. 

Treatment. — The treatment of telangiectasis is sim- 
ple. It is only necessary to introduce the electrolytic 
needle into the red central spot, and allow a current of 
about 2 ma. to flow for a minute or so. The mode of 
operating is similar to that used in destroying superfluous 
hair, and is decribed in the section on Hypertrichosis. 
It may be destroyed by touching it with a drop of nitric 
or trichloracetic acid, or puncturing it with a white-hot 
needle. 

Tinea Imbricata or Tokelau Ringworm. — According to 
Castellani 1 this is not a true ringworm, but is due to the 
endodermophyton. Its home is in the Malay peninsular 
from which it has spread to China, Burma, and Ceylon. 

1 Brit. Jour. Dermat., 1913, xxv, 377. 



TINEA IMBRICATA 683 

Symptoms. — It begins with one or more round or oval, 
slightly raised, dark brown, very itchy patches. The 
centre of each patch splits and a ring of flaky large 
scales form, the scales being attached at their periphery. 
The rings enlarge and another brownish patch appears at 
the site of the first brow T n patch in its centre. The second 
brown patch undergoes the same evolution, and so on 
until a number of concentric rings are formed. Some of 
the spreading rings will fuse together and complex figures 
will be formed. A large part of the surface of the body 
may be covered by these rings. The eruption may beaome 
diffused,, the rings disappear, and nothing be left but a 
mass of typical scales overlapping each other. 

The scales are flaky, resembling tissue paper, dry, dirty 
gray or brown in color, and slightly curly. Each one has 
a free border and is attached by the opposite edge, the 
free border being toward the centre of the patch. If they 
are removed they will leave concentric circular dark lines. 

There may be eight or ten rings in the patch. The 
scalp is free. The nails may become much thickened 
with rough surfaces and deep cracks. The disease itches 
in warm weather and is very chronic. Eosinophilia, 
anemia, and weakness may result. 

The fungus resembles European ringworm, but is more 
abundant in the scales. It grows between the superficial 
and deep strata of the epidermis and does not attack the 
hair. 

Diagnosis. — Ringworm differs from it in being more 
inflammatory, in having smaller scales and less abundant 
fungus, in attacking the hair, and in lacking the concentric 
circles. 

Treatment. — Formalin in 40 per cent, solution is 
useful. The pain it causes may be relieved by ice packs. 
Iodine, in tincture and liniment help. Resorcin, 10 to 20 
per cent, in compound tincture of benzoin, applied to a 
part of the surface at a time and continued for several 
weeks. Very hot baths and scrubbing with sand soap. 
Such are the remedies found most useful. 



684 DISEASES OF THE SKIN 

Tinea Nodosa. — This is a condition of incrustation of 
the hairs with a fungous growth forming dry, hard, 
elongated, formless masses varying in color from olive to 
brownish yellow, giving a rough feel to the hair. The 
hair follicles are unaffected, and the hair is firmly seated 
in them. The hair may be simply incrusted or it may 
be split. The free end of the hair is more affected than 
the proximal end. The spores composing the incrusta- 
tions are similar to the trichophyton, but smaller. It is 
seen especially on the hairs of the beard and moustache. 
It differs from piedra in not affecting the scalp hair and 
in its fungus. The best treatment is to shave the hair 
off. If this is objected to the nodes may be removed 
by the frequent application of sweet oil with 2 per cent, 
of salicylic acid. 

Tinea Trichophytina. — See Trichophytosis. 
Tinea Versicolor. — See Chromophytosis. 

Trichiasis. — This is a congenital or acquired displace- 
ment of the cilise so that they point backward and scratch 
the cornea. Both lids of both eyes are usually affected. 

The best treatment is the destruction of the hair by 
means of the electrolytic needle, as described in the 
section upon Hypertrichosis. 

Trichophytosis. — A contagious disease of the skin and 
hair, occurring most often in children, due to the invasion 
of the epidermis by the trichophyton fungus, and charac- 
terized by the formation of circular or annular scaly 
patches, and partial loss of hair. 

As its name indicates, this is a disease produced by the 
trichophyton fungus. It may find lodgement and grow 
on the general cutaneous surface, in the scalp, beard, or 
nails — that is, in the epidermic structures. In these dif- 
ferent localities it develops so differently as to produce 
very different clinical pictures. We shall describe each 
one by itself and give its differential diagnosis, treating 
all matters of etiology and treatment collectively. 



TRICHOPHYTOSIS 



685 



Trichophytosis Corporis. — Synonyms: Tinea circinata; 
Herpes eircinatus; (Fr.) Herpes cireine, Trichophytie 
circinee; (Ger.) Scheerende Flechte; Ringworm of the 
body. 

Fig. 106 




Trichophytosis corporis. (By the courtesy of Dr. S. Dana Hubbard.; 

Symptoms. — This is the simplest and most readily 
cured of all the forms of ringworm. It begins as a small, 
pale red, slightly raised spot, which, growing, spreads out 
into a round, sharply defined, scaly patch; then it clears 
up in the middle, becomes ring shaped, and advances 
with a raised border that may be vesicular; or crusted 
from the drying of the veiscular contents; or papular and 
scaly. After a time it either ceases to spread, or, en- 
larging, the edge of the ring becomes broken in places. 
At last it undergoes spontaneous involution. There may 
be but a single patch or there may be a number of patches. 



GSG DISEASES OF THE SKIN 

If two circles meet at their peripheries, they coalesce and 
form gyrate figures. Very often rings do not form, and 
we have only a round, sharply defined, scaly, circular 
patch. The exposed parts — face, hands, and neck — are 
the most common sites for the eruption. In rare cases 
ringworm may be widely disseminated over the body. A 
slight amount of itching is the only subjective symptom, 
and that may be wanting. 

Another form of ringworm of the body is that known 
as eczema marginatum, which is ringworm located in 
the crotch . or axilla. It is usually of a more highly in- 
flammatory character than the same disease on other 
parts of the body, and resembles an eczema very closely — 
in fact, it is often complicated by an eczema. The edge 
of the patch is sharply defined, raised, scalloped, papular, 
and scaly, while the centre may be smooth or pigmented 
and crusted. The patch often attains large dimensions, 
running down the inside of the thigh, up over the abdo- 
men, and backward over the perineum. Usually the 
inside of both thighs is affected. There is considerable 
itching. The same symptoms are presented when the 
axilla? are affected. There is also a true eczema of the 
crotch to which the same name has been given, that is 
not due to the trichophyton, but resembles the form just 
described. Sabouraud has shown that most of these 
cases are due to a special form of fungus, as the reader 
will find in the article on eczema marginatum on p. 261. 

Tinea albigena is a form of ringworm seen in the 
Malay Archipelago, on the coast of Africa and perhaps 
elsewhere. It is peculiar in that for the most part it 
affects only the palms and soles, though it may spread 
and affect the nails. It begins as small itchy papules 
upon which bullae form that break and are followed by 
scaling and redness of the skin. There may be thickening 
of the soles, making walking painful. Leucodermatous 
patches may form. Patches formed of irregular shape. 
The disease is very chronic in its course. • The nails if 
diseased lose their transparency, and become thinned. 



TRICHOPHYTOSIS 687 

Diagnosis. — Trichophytosis corporis is readily diag- 
nosed, as its appearance is distinctive. Favus of the body 
may spread out into a circular patch, but soon it will 
show the distinctive sulphur-yellow cupped crusts. 
Psoriasis on the body will have a brighter red color; its 
scales will be more abundant, thicker, and brighter; it 
will be found on the tips of the elbows and over the knees, 
and will be more profuse and disseminated; and examina- 
tion of the scales will show an absence of fungus. The 
scaling papular syphilide or the squamous syphilide will 
not itch; there wdll be no fungus in the scales; the color 
will be that of raw ham; the base will be more infiltrated; 
it will run a more chronic course, and will not yield so 
readily to treatment. Seborrhea of the chest may occur 
in rings, but its location will suggest its origin; the skin 
is greasy, the scales rub off easily, and there is no fungus 
in them. Eczema of the crotch or axilla differs from 
ringworm of the same region in not having a so sharply 
defined and scalloped or festooned border; in forming a 
more evenly diseased patch with no sound skin in it; and 
in having no fungus in the scales taken from it. Pity- 
riasis rosea is more widely distributed than is ringworm, 
and spreads more rapidly; it is not so scaly; has a more 
yellowish centre; is usually more abundant on the trunk; 
shows no fungus under the microscope, and the eruption 
is made up both of macules and rings. 

Trichophytosis Capitis. — Synonyms: 1 Herpes tonsurans 
seu circinatus, seu squamosus; Tinea tonsurans, seu 
tondens; Porrigo furfurans; Dermatomykosis tonsurans 
(Kobner); (Fr.) Herpes tonsurante, Teigne tondante ou 
tonsurante, L'herpes circineparasitaire; (Ger.) Scheerende 
Flechte; (Slav.) Ringskurv; Ringworm of the scalp. 

Symptoms. — This form of ringworm is seen almost 
exclusively in infants and children. As puberty or early 
adult life is reached the disease, no matter how long con- 

1 I can mention here only the more common ones, as their number 
is legion. 



688 



DISEASES OF THE SKIN 



tinued, and how severe it may be, tends to get well of 
itself. It begins as a single vesicle or a small, insignifi- 
cant, red, scaly spot that would pass without suspicion 
of its nature unless other cases of ringworm put us on our 
guard. From this small beginning the disease spreads 



Fig. 107 




Trichophytosis capitis. 1 (Fox.) 



peripherally to form a circular patch, which is covered 
with grayish scales, sharply defined, perhaps slightly 
elevated, and partially bald, and slightly if at all red, or 
the patch may be a little elevated, reddened, and crusted 
looking like a patch of eczema. Inspection of the patch 
will show a number of broken-off stumps of hairs with 

i G. H. Fox: Skin Diseases of Children. Wood, N. Y., 1897. 



TRICHOPHYTOSIS 689 

split ends. These stumps are characteristic of the dis- 
ease. The hair growing in and about the patch is dry, 
lustreless, split, and brittle. Attempts at epilation break 
it off, and if it is indented with the finger-nail it will take 
a sharp angle and retain it. This shows that it has 
lost its resiliency. Apparently healthy hairs are some- 
times growing from the patch. The size of the patch 
varies greatly. It may be no larger than that of a ten- 
cent piece, or it may be so large as to denude a good part 
of the scalp. These large patches are usually formed by 
the coalescence of several small ones, and then they lose 
their circular outline and become scalloped. There may 
be but a single patch, or there may be a number of them. 
After attaining the size of a half-inch to one inch in 
diameter the patches may remain stationary in size or 
increase slowly. The most frequent sites are the vertex 
and parietal regions. Pruritus of greater or less degree 
is usually complained of, and it may be the first symptom 
that draws attention to the child's scalp. The course of 
the disease is exceedingly chronic. It does not produce 
permanent baldness. It is most commonly caused by the 
microsporon Audouini, a small spore fungus. This is the 
typical gray patch "ringworm," as seen in the vast 
majority of cases. 

Sometimes, instead of being scarcely or not at all 
raised above the surface of the skin, the patch usually 
a single one, begins to swell up, becomes raised, uneven, 
and boggy, and we have the condition described as 
kerion (which see). The granuloma trichophyticum of 
Majocchi is simply a form of kerion. Another variety 
is what Liveing terms bald tinea tonsurans. This begins 
as an ordinary ringworm, but after a time the hair all 
falls out, the scalp is smooth and without scales, as in 
alopecia areata, and at its border there may be found 
short broken hairs, like those seen in the latter disease. 
At first this change takes place in one patch alone, and 
we will be guided to a right diagnosis of the disease by 
the appearance of the other patches. Later, these too 
44 



690 DISEASES OF THE SKIN 

become altered, and then it would be hard to make the 
diagnosis without the history of there having been scaly 
patches. This is an infrequent form of the disease. 

Still another form is called disseminated ringworm. 
Here the patchy character of the disease has disappeared, 
the hair has apparently grown in nicely, and there is seem- 
ingly only a scurvy condition of the scalp. This is a dan- 
gerous form, because the child is often regarded as well 
and yet is quite capable of spreading infection. Careful 
examination of the case, by causing the child to stand with 
his back to the physician, and turning the hair slowly 
backward against its direction of growth, will show here 
and there " stumps," and also the presence of hairs that 
stand up from the head for a few moments. Normal 
hair falls quickly back into place, which is not the case 
with hair affected with ringworm. Most of these cases 
are caused by trichophyton crateriforme, a large spore 
fungus, though some are due to a small spore fungus. 

A pustular form is sometimes described. It is simply 
a ringworm occurring in a strumous subject, in whom all 
inflammatory skin diseases are prone to assume a pustular 
character. 

Diagnosis. — Trichophytosis capitis must be differenti- 
ated from alopecia areata, favus, eczema, seborrhea, and 
psoriasis. From alopecia areata it differs in being scaly; 
in not producing perfectly bald patches ; in its much slower 
progress; in the presence of "stumps," and in having the 
trichophyton fungus in the hair, as seen under the micro- 
scope. From f amis it differs in the absence of the sulphur- 
yellow cupped crusts of that disease; in not having such 
heaped-up asbestos-like crusts; in forming distinct round 
patches; in the more brittle character of its hair; in not 
producing red, smooth, permanently bald spots that later 
become white and cicatricial, and in showing a marked 
tendency to get well of itself as puberty is reached. The 
diagnosis between them by the microscope is not easy 
without a knowledge of the appearance on the skin. The 
spores of favus are more polymorphous and somewhat 



TRICHOPHYTOSIS 691 

larger than those of trichophytosis, and its mycelia are 
more abundant than its spores. From eczema it differs 
in the more circumscribed and circular character of its 
patches ; in being less itchy, and in the presence of broken- 
off hairs and stumps. The presence of these broken-off 
hairs and stumps, and of the fungus in the hair and scales, 
will sufficiently distinguish ringworm from both seborrhea 
and psoriasis. 

Trichophytosis Barbae. — Synonyms: Tinea sycosis, seu 
barbae; Sycosis parasitaria seu parasitica; Herpes ton- 
surans barbae (Fr.) Trichophytie sycosique, Sycosis 
parasitaire; (Ger.) Parasitische Bartfinne; (It.) Sicosi 
parasitaria; (Eng.) Barber's Itch, Ringworm of the beard. 

When the trichophyton invades the beard, it may take 
the form of a superficial scaly circular patch which 
increases in size, just as on the scalp, producing broken-off 
hairs and a partially bald area. There may be several 
of these areas upon the chin and cheeks. Or it may take 
the more usual form in which there will be either some 
pustules pierced by hairs, or else a group of large nodular 
swellings, varying" in size from that of a split pea to 
that of a half -cherry, arranged in the form of a circle. 
There are usually several groups of them. The nodules 
are prominently raised and usually rounded (Fig. 108). 
They are of a congested red or purple color. They may 
be hard and scaly; or give exit to a sticky discharge; or, 
rarely, suppurate. The hair over them is broken, or 
more or less wanting. Usually itching and burning are 
complained of. In some cases instead of distinct nodules 
there is a condition resembling kerion. The disease is 
usually limited to the chin and anterior part of the neck. 
More rarely it involves the whole bearded portion of the 
face. 

Diagnosis. — The disease is to be differentiated from 
sycosis, pustular eczema, and the tubercular syphilide. 
From sycosis it differs in affecting the lower part of the 
face and sparing the upper lip; in presenting broken-off 
hair; in having grouped nodules, and in the presence of 



692 



DISEASES OF THE SKIN 



the fungus in the hair. Sycosis is more acute in its mani- 
festations, and is characterized by its many discrete pus- 
tules pierced by hair. From eczema it differs in the same 
points as it does from sycosis, and also in being less crusted, 
and in the ease with which the hair can be plucked or will 
break. Eczema is also a disease of the skin and not of the 

Fig. 108 




Trichophytosis barbae. (From Prof. G. H. Fox's service in the 
Vanderbilt Clinic.) 



hair. The tubercular syphilide bears a resemblance to 
trichophytosis barbae at times. It differs from it in 
forming but a single group, in being of a darker color, 
and in undergoing a steady course of development toward 
final recovery, leaving, not infrequently, permanent scars. 
Other symptoms of syphilis will often be found, and its 
whole history will be different. 



TRICHOPH YTOSIS 693 

Trichophytosis Unguium, or onychomycosis, is ring- 
worm as it affects the nails. It begins as a change in 
color of the nail-substance and with a loss of its trans- 
parency. The nail becomes uneven and thickened, and 
its edge, which is usually the part first attacked, becomes 
raised from its bed by an accumulation of scaly matter 
under it. A progressive atrophy takes place, and at last 
the nail breaks and falls either in part or as a whole. 
There may be but one nail affected, or all the nails, both 
of the hands and feet, may be attacked, then usually con- 
secutively. Many obscure cases of atrophy of the nail 
will be found to be due to ringworm when the scrapings 
from them are examined under the microscope. 

Diagnosis. — The appearances presented by the nails 
are so similar to those seen in psoriasis and other diseases 
in which the nails become atrophied, that a positive 
diagnosis can be made by the microscope only, unless 
there should be symptoms of the one or the other disease 
present elsewhere on the body as a guide. 

Having now described the different varieties of ring- 
worm with their differential diagnosis, we pass on to 
study the factors common to all. 

Etiology. — The cause of the disease is contagion 
with the trichophyton fungus. This contagion may be 
direct, from person to person, or indirect by means of 
brushes, towels, clothing, and the like. It is possible 
that the air may become so full of the fungus in epidemics 
in crowded children's asylums that contagion may be by 
means of the fungus lighting upon the head or body. The 
disease is very contagious, much more so than is favus. 

As the disease is quite common in dogs, cats, and 
horses, constituting in them one form of mange, they are 
a very frequent source of contagion. Ringworm of the 
scalp is often communicated by means of brushes and 
headgear. Ringworm of the beard is conveyed by means 
of brushes, towels, and the barber's fingers. Ringworm 
of the nail comes from scratching. Some skins seem to 
furnish a better soil for the growth of the fungus than do 



694 



DISEASES OF THE SKIN 



others. Children have ringworm of the scalp; adults 
almost never. There is no peculiarity of constitution that 
predisposes to the disease. It attacks all classes and is seen 
in all conditions of society, though, of course, it is most 
common among the crowded poor. The gray non-inflam- 
matory patches on the scalp are caused by the micro- 
sporon Audouini, and the inflammatory form as well as 
Kerion are due to either the ectothrix or the endothrix 

Fig. 109 




Trichophj'ton tonsurans in hair shaft and follicle. (After Kaposi.) 



forms of trichophyton. The last two also cause most 
cases of ringworm of the body and beard. Tinea imbri- 
cata is said to be due to an aspergillus. 

Pathology. — The fungus of ringworm has its habitat 
in the epidermic structures of the skin. On the general 
cutaneous surface it is so superficially located as to be 
readily destroyed. When it attacks the hair and nails it 
penetrates below the skin in their epidermic structures, 
and is much more difficult of cure. 



T RICH OP H YTOSIS 695 

The fungus (Fig. 109) consists in mycelia and conidia 
(spores) the proportion of which to each other varies: in 
the hair of the scalp and beard the number of spores far 
exceeds that of the myceiia. Sometimes they are so 
numerous as to be crowded together in lines. On the gen- 
eral surface the mycelia are far more numerous. They 
are long, slender, branched, straight or crooked bodies. 
The spores are round, small, and refract light. Having 
become lodged in the skin, the fungus always sets up a 
certain amount of irritation by its processes of growth. 
If it lands upon hairy regions, it attacks the hair second- 
arily, passing down the walls of the hair follicle to a 
greater or less depth before it penetrates the cuticle of the 
hair and gains access to its substance. Having gained 
access, it vegetates freely, and may often be traced 
throughout the whole length of the hair. Robinson and 
others have found the fungus in the perifollicular tissue. 
Its presence always causes more or less perifolliculitis. 
If the perifolliculitis is very great, permanent baldness 
may result. In trichophytosis unguium the fungus grows 
in the substance of the nails. 

Sabouraud 1 and others have demonstrated that there 
are several fungi producing ringworm, the most common 
being the trichophyton microsporon or microsporon Au- 
douini, and the trichophyton endothrix and ectothrix. The 
endothrix fungus grows in the hair, while the ectothrix 
fungus grows about the hair forming a sleeve or cuff to 
the hair. C. J. White, 2 repeating Sabouraud's investi- 
gations in this country, says that 52 per cent, of ringworm 
in this country is due to the microsporon, most all being 
on children's scalps. In England 90 per cent, of the cases 
are due to this form of trichophyton, and so the propor- 
tion varies in different countries. A similar fungus is 
found on animals. In the hairs the spores are small, 
round, glistening, and placed closely together. They are 

1 Diag. et Trait, de la Pelade et des Teignes de l'Enfant. Paris, 
1895. 

2 Jour. Cutan. and Gen.-Urin. Dis., 1S99, xvii, No. 1. 



696 DISEASES OF THE SKIN 

more equal in size than are those of the other forms of 
ringworm. Having penetrated the hair, the fungus 
grows in the hair substance in the form of long, jointed 
mycelia, fine branches from which, penetrating the 
cuticle, form ectospores on the surface of the hair. The 
microsporon does not grow well on the skin, but is found 
in some cases. The other forms of ringworm fungi 
rarely affect the scalp. The trichophyton endothrix in the 
hair grows in lines parallel to its long axis. Its spores are 
quadrangular, with rounded corners, and vary consider- 
ably in size. It has thus far been found only in humans. 
It causes most cases of ringworm of non-hairy parts, and 
some cases of ringworm of the scalp, especially those 
that have an eczematous appearance. The ectothrix 
variety most often affects the bearded portion of the 
face, and causes the deep or suppurating forms of ring- 
worm. It also produces kerion of the scalp, and many 
cases of trichophytosis corporis. The spores resemble 
the preceding, but grow around the hairs rather than in 
them. It is a pyogenic fungus, and is derived directly 
or indirectly from animals. The different forms of fun- 
gus show more divergence in cultures than in their 
natural state. 

Treatment. — There is no disease of the skin much 
more easy of cure than trichophytosis of the general 
surface of the skin, and none much more difficult of cure 
than trichophytosis capitis. 

Trichophytosis corporis may be readily cured with 
almost any slightly irritating and astringent application, 
and by all the antiparasitics. It may be cured by means 
of common ink, or by using vinegar in which a copper 
coin has been soaked. The scales should be removed 
with soap and water, and an ointment of sulphur, or 
ammoniate of mercury, or chrysarobin, or pyrogallol, be 
applied ; or tincture of iodine, acetic or sulphurous acid, or 
a solution of bichloride of mercury, 3 to 5 grains (0.194 
to 0.33) to the ounce (32) may be used. The last is a 
good method for adults, as it does not stain the skin, and 



TRICHOPH Y TOS fS 697 

one application will usually cure the disease. It is rather 
too strong for children. Other applications are a saturated 
solution of hyposulphite of soda; oleate of copper, \ a 
drachm (2) to the ounce (32) of ointment; and salicylic 
acid, 5 to 10 per cent, strength, which by no means 
exhausts the list. 

Trichophytosis cruris et axillce, or eczema marginatum 
is not so easy to cure as the preceding variety, but it can 
be cured by any of the means detailed above. In using 
chrysarobin, here as elsewhere, we should bear in mind 
its irritant qualities. Taylor has recommended painting 
the parts with 2 or 4 grains (0.12 to 0.24) of bichloride of 
mercury in 1 ounce (32) of tincture of benzoin. Harda- 
way speaks well of modified Wilkinson's ointment. Some 
cases will make a good recovery under an ointment con- 
taining oil of cade, 1 drachm to the ounce (4 to 32) . This 
is specially good after the use of sulphur or other anti- 
parasitic to kill the fungus, as it is curative of the eczema 
that often remains. 

Trichophytosis capitis is the most obstinate form of 
ringworm to cure. The fungus is present abundantly 
deep down in the skin, and each hair is a separate focus 
of disease. The difficulty we have to contend against is 
to cause our remedies to enter the skin deeply enough to 
destroy the fungus. Nature gives us a hint as to the 
cure of the disease when a kerion forms that is not infre- 
quently followed by disappearance of the disease. Most 
of the so-called remedies for ringworm are irritant to the 
skin, and do good quite as much by the irritation they 
cause as by their parasiticide properties. 

If we see the case at its earliest stage, we may some- 
times succeed in aborting the disease by the application of 
the bichloride of mercury, 5 or 10 grains (0.33 to 0.66) to 
the ounce (32) . Usually when the case is brought to us it 
has gone too far for aborting it. Then we may sometimes 
cure the case promptly, but most often it is an affair of 
months and, perhaps, years. The first requisite for a cure 
is faith on the part of the patient, so that the second ele- 



698 DISEASES OF THE SKIN 

ment, persistency, can come into play; and then by the 
persevering use of parasiticides a cure may be effected. 
As each case is a source of contagion, steps must be taken 
to isolate the case if it occur in an asylum or school. 
If it occur outside of an institution, the parents must 
be cautioned not to allow the child's hat or clothing 
to be worn by any other child, and the child must be 
taken out of school. To assure still further the safety 
of others, an antiparasitic must be applied to the child's 
scalp, such as a 1 or 2 per cent, solution of salicylic acid 
in alcohol and castor oil. The child should also wear 
a linen cap over the whole head. These regulations are 
difficult to carry out in private practice. 

The ringworm patch or patches should be scrubbed 
with soap and water so as to remove all the scales before 
we make any local application. Tar soap is a good one 
to use for the purpose. Then the hair should either be 
cut short, pulled from or shaved off the patches, and for 
about a quarter of an inch about them. Now the case 
is ready for the chosen parasiticide. Whatever is used 
in the form of an ointment or oil, it should not be 
smeared over the surface, but worked in, as it were. 
One of the oldest and most used of them is the official 
sulphur ointment, full strength or diluted according to 
reaction. One of the best ointments is: 

1$ — Ac. salicylic, gr. x 66 

Sulphur precipitat., 3j 4 

Adipis lanse, 5 vj 24 

Adipis anserini, ad 5j 32 

01. rosae geran., gtt. x gtt. x 

The persistent daily use of sulphur ointment, combined 
with epilation, and scrubbing of the patch with soap 
and water about once a week, may cure the disease. 
Sulphur may also be used in combination with other 
drugs. One of the most efficient remedies in chronic, 
obstinate cases is 

I^— Ol. tiglii, 3.1 41 

Ungt. sulphuris, 3J 32l M. 



TRICHOPHYTOSIS 699 

This is to be rubbed into the patch once a day until symp- 
toms of reaction appear, the patch becoming swollen and 
red. When this subsides the patch will be smooth like as 
in alopecia areata. There is always danger of producing 
permanent baldness, but thus far in all my cases the hair 
has come in all right. As nothing has yet been found to 
render sulphur soluble in any amount, it must always be 
exhibited in ointment or paste form. 

Mercury is another old stand-by. It may be used as a 
solution of the bichloride in alcohol (grs. j-iij ad § j), whose 
application should not be intrusted to any one but a physi- 
cian or trained nurse. It is to be used two or three times 
a day, its effect carefully watched, and, of course, it should 
not be applied to large surfaces. It may be employed as 
recommended by Kerley, 1 who reports having cured a 
number of cases in from two to twenty weeks by using a 
solution made by adding 2 grains (0.12) of the bichloride 
dissolved in sufficient alcohol to \ (16) ounce each of 
kerosene and olive oil, daily rubbed into patches as well as 
applied all over the scalp. When inflammation is caused, 
the application is stopped, and a simple ointment is used 
until the irritation subsides. Then the bichloride is again 
applied. The scalp is to be washed often. He thinks that 
a cure will be hastened by using a saturated solution of 
iodine on alternate days with the bichloride solution. 
Crocker thinks highly of the bichloride, 3 grains (0.18) 
dissolved in alcohol, to the ounce (32) of turpentine. 
Tincture of benzoin is a good excipient for the bichloride, 
according to Leviseur, 2 who recommends the application 
of it 1 to 2 parts to 300 parts of benzoin, once a week, 
with the daily use of salicylic acid ointment in 10 to 
20 per cent, strength. All the mercurial ointments are 
useful, but are not so prompt in their action as other 
remedies. 

The remedies recommended in the treatment of ring- 
worm of the body are all of use in the same disease of the 

1 New York Med. Jour., 1891, liv, 390. 

2 Med. Roc, 1889, xxxv, 594. 



700 DISEASES OF THE SKIN 

scalp, and need not be repeated here. The main modi- 
fication is the epilation that should precede their applica- 
tion. Instead of using tincture of iodine, the English 
authors commend Coster's paint, made of 2 drams (8) of 
iodine and 6 drachms (24) of the light oil of wood-tar, 
which is to be firmly applied with a stiff brush. A black 
crust will form after two or three days, which should be 
removed with the forceps. The part should then be washed 
with soap and water, and the paint again applied. Two 
or three applications of it may be made to an infant's 
scalp, or it may be continued longer in children over four 
years of age. The best way of using iodine, and in my 
experience the best treatment for ringworm, excepting when 
x-rays can be used, is to rub up 1 drachm (4) of the crystals 
of iodine in 1 ounce (32) of goose-grease. This is to be well 
rubbed into the patches with a stencil or stiff paint brush. 
It causes but little reaction and cures many cases speedily. 
The iodine is found staining the hairs deeply when the hairs 
are examined under the microscope. 

Chrysarobin in 10 per cent, strength in traumaticin or 
collodion is good, its tendency to produce dermatitis being 
ever borne in mind. It may be suspended in glycerin and 
painted on once daily until redness and swelling appear. 
Then olive oil is to be applied until the reaction subsides. 
Then the part is to be washed with soap and water and 
the chrysarobin reapplied, and so continued until a cure 
is affected. Pyrogallol in 5 to 15 per cent, in the same 
excipients, with or without the addition of \ drachm (2) 
of salicylic acid to the ounce (32), is a reliable preparation. 
(3-naphtol and hydronaphiol are commendable. Naphtol 
may be used as a 1 per cent, solution in alcohol, or in the 
form of a paste, as recommended by Kaposi: 1 



M. 



I&— 0-Naphtol, 


gr. xv 


1 


Spt. sap. viridis, 


gr. xxx 


2 


Alcohol, 


Siss 


50 


Bals. Peruv., 


gr. xxx 


2 


Sulph. loti, 


3iiss 


10 



1 Wien. med. Wochenschr., 1881, xxxi, 617. 



TRICHOPH YTOSIS 701 

Either may be applied twice a day for two or three days, 
and then followed by a thorough scrubbing with green 
soap. Thymol in 5 to 10 per cent, strength, dissolved in 
chloroform and olive oil, is recommended by Malcolm 
Morris. Formalin is commended by some, but con- 
demned by others, on account of the severe irritation 
it is capable of setting up. 

Harrison 1 endeavored to effect entrance of his remedies 
to the deeper parts of the skin by first applying to the 
scalp solution Xo. 1, composed of \ a drachm (2) of potas- 
sium iodide in 1 ounce (32) of liquor potassse. After a 
few days he applied solution Xo. 2, composed of 3 grains 
(0.12) of corrosive sublimate to 1 ounce (32) of sweet 
spirits of nitre or of water. This treatment requires care- 
ful watching. Foulis 2 recommends rubbing turpentine into 
the scalp, after cutting the hair, until it smarts. Then the 
scalp is to be scrubbed with 10 per cent, carbolic soap, 
dried, and painted with two or three coats of tincture of 
iodine. When dry the whole head is to be anointed with 
carbolized oil, 1 to 20. This procedure is to be carried out 
once a day. Alder-Smith has found useful a saturated 
solution of boric acid, as follows: 



I^ — Ac. boric, 


3iv 




16 




^Etheris, 


5v 




150 




Alcoholis, 


ad 5 xxx 


ad 


1000 


M 



It is to be freely applied after washing the head in the 
morning, and two to five times during the day. 

H. B. Sheffield 3 recommends clipping the hair close, and 
applying over the whole scalp once a day for five days 



— Ac. carbolici, 










01. petrolati, 


aa 


OSS 


aa 


15 


Tinct. iodini, 










01. ricini, 


aa 


5.i 


aa 


30 


01. rusci, 


ad 


3iv 


ad 


120 



M. 



This is to be wiped off with a cloth on the sixth day, the 
hair clipped, and the scalp thoroughly washed with green 

1 Bri. Med. Jour., 1885, ii, 134. 2 ibid., 1885, i, 536. 

3 New York Med- Jour., 1898, lxvii, 680. 



aa 


3J 
5i 


aa 


4! 
30 




ad 


oiv 


ad 


120 


M. 



702 DISEASES OF THE SKIN 

soap. On the seventh day the treatment is to be re- 
peated, and so on for three or four weeks, or until no mofre 
fungus is found and new hairs appear. A 10 per cent, 
sulphur ointment is then to be used for a few days, and 
for two weeks afterward 

1$ — Resorcin., I 

Ac. salicylici, 
Alcoholis, 
01. ricini, 

In very chronic cases and in the disseminated form it 
may be necessary to blister the patch by means of croton 
oil or acetic acid. Croton oil must always be used with 
caution and to small areas, as it is capable of producing 
permanent baldness. One part in ten of olive oil is 
usually sufficient, but the strength may be increased till 
we have it sufficiently strong to cause a mild degree of 
pustulation, when the hairs may be easily plucked. In 
disseminated ringworm a drop of the pure oil may be 
applied to each diseased follicle, and as soon as a pustule 
forms the hair should be pulled out. Whitfield advises 
using for this purpose, a No. 16 sewing needle bent to an 
angle of 45 degrees, dipping the eye end into the oil, and 
passing it into the follicle. The hair is to be pulled out in 
a few minutes. In very obstinate cases electrolysis may 
be employed to individual hairs, which, like the croton 
oil will permanently destroy the hair. A. Van Har- 
lingen 1 advises the use of a 10 to 20 per cent, tincture or 
ointment of epicairin rubbed in twice a day and claims 
to cure the disease in five weeks. Others have had the 
same experience. 

Epilation is of positive value in treating this obstinate 
disease, even though the hair does break off. Some hair 
with its fungus will come out, and the follicular mouths 
will be rendered more open for the entrance of the appli- 
cations, which should always follow epilation. Besnier 

1 Amer. Jour. Med. Sci., 1903, cxxv, 1012. 



TRICHOPH YTOSIS 703 

epilates around the patches, and asserts that then the 
disease rarely spreads to neighboring parts. 

The speediest, neatest, and most effective treatment, 
especially where there are several patches, is by arrays. 
The method has been perfected by Sabouraud and 
Noire. They place the patient after cutting the hair 
from over the patch, if but a single one, or from the 
whole head, if many patches, at 15 cm. from the anti- 
cathode of a self -regulating Miiller tube of 8 cm. diameter. 
At 1\ cm. from the anticathode they place in a proper 
holder a pastile made of bristol board coated with an 
emulsion of platino-cyanide of barium in collodion with 
acetate of starch. This is covered with black paper. 
The exposure is continued until the pastile assumes 
the tint of a standard color "B," which comes with the 
book holding the pastiles. But one exposure is made. 
In fifteen days the hair falls. In two months it comes 
in healthy. During this time the head is covered with 
an antiseptic wash. 1 

Treatment should be continued until there are no more 
stumps or broken-off hairs to be seen; till the microscope 
fails to reveal any fungus in the hair after prolonged 
search, and until the scalp is no more scaly. It is well 
to use the following: 



-Hydrarg. ammon., 


3j 


133 


Hydrarg. chlor. mitis, 


3ij 


2|66 


Vaselini, 


§j 


32| M 



or a sulphur ointment for several months after apparent 
cure. 

Trichophytosis barbae is treated along the same lines as 
when the scalp is the seat of the disease. The beard 
should not be shaved, but cut short with scissors. Here 
epilation is of more positive value, as the hairs over the 
nodules will come out easily. It is possible to abort the 

1 For further details of the use of z-rays see Jackson and McMurtry, 
Diseases of the Hair and Scalp, Phila., 1913. 



704 DISEASES OF THE SKIN 

disease before it has implicated the hair by the application 
of a solution of 5 to 10 grains (0.33 to 0.66) of bichloride 
of mercury in an ounce (32) of alcohol. A 10 per cent, 
solution of resorcin or an ointment of the same strength 
may accomplish the same end. After the disease has got 
fully under way, systematic epilation, daily shaving by 
the patient himself, and the thorough application of one 
of the parasiticide preparations mentioned in the pre- 
ceding sections, especially the iodine goose-grease, will 
effect a cure, x-rays may be used as in ringworm of 
the scalp. 

Trichophytosis unguium may be treated by producing a 
paronychia. This may be done by Pellizzari's 1 method of 
keeping green soap upon the nail under a rubber cot for 
a few days, until the nail is softened. Then equal parts 
of olive oil and pyrogallol are to be applied till the nail 
loosens, when it is to be removed and the finger dressed 
with iodoform. Thin 2 recommends scraping the affected 
nails very thin, applying liquor potassse to soften them, 
and then dabbing on creosote, or acetic acid, or a solu- 
tion of 2 to 5 (0.12 to 0.33) grains of bichloride of mercury 
in an ounce (32) of alcohol. Crocker speaks well of using 
Harrison's plan for treating ringworm of the scalp, which 
see. Solution No. 1 should be applied after scraping and 
kept on for fifteen minutes, covered with oiled silk; then 
No. 2 applied in the same way and kept on for twenty-four 
hours. These should be repeated till the cure is effected. 
If the skin should become tender or begin to peel, the 
solutions should be stopped, and one of hyposulphite of 
soda used until the skin heals. A 10 per cent, salicylic 
acid plaster worn constantly over the nail and thrust 
under it is a good remedy, x-rays may also be used. 

Prognosis. — All forms of ringworm, excepting that of 
the general surface of the body, are very obstinate, but 
perservering and intelligent treatment will cure them. 
The most obstinate form is that of the scalp, and a 

1 Giorn. Ital. d. Mai. e del Pelle, March, 1888. 

2 Practitioner, May, 1887 et seq. 



TRYPANOSOMIASIS 705 

speedy cure should never be promised. It must always 
be remembered that as puberty is reached ' it tends to 
spontaneous cure. 

Trichorrhexis Nodosa. — See Atrophia pilorum propria. 

Trypanosomiasis. — This is part of the disease known 
as "Sleeping Sickness." It is due to the entrance into 
the skin of a poison introduced by a fly known as Glossina 
palpalis. The description here given is taken from a 
paper by H. Darre. 1 

In some cases a more or less severe inflammatory 
reaction immediately follows the sting of the fly. Usually 
this does not come on until several hours afterward. 
The next day there will be either a little tumor looking 
like a blind boil, or a red, violaceous, round, slightly 
raised lesion the size of a twenty-five-cent piece. They 
are slightly tender, and always accompanied with swelling 
of the neighboring lymphatic glands. In some cases the 
reaction is more violent and attended with oedema and 
fever. Usually in a few days they are gone, leaving 
only passing pigmentation. They are found most often 
on the neck, legs, knees, sides of the chest or axilla. 
They are followed by an eruption of vesicopapules 
which are very pruritic, or of polymorphous urticarial 
erythema which is non-pruritic. 

The vesico-papules are red, and the vesicles dry down 
into crusts. They leave a brown pigmented lesion with 
depressed centre. The eruption may be general, but 
usually is more pronounced on the arms and chest, and 
is of no great diagnostic significance, as this form of 
eruption is very common in Africa. 

The polymorphous erythema of circinate type is of 
more importance. It is not constant but frequent. It 
may occur early in the disease, but generally appears 
some months after the initial fever. The lesions are 
violaceous red, disappear completely on pressure, slightly 

1 Annal. derm, et, syph., 1908, ix, 673. 
45 



70G DISEASES OF THE SKIN 

elevated, and the skin is (edematous but not infiltrated. 
Both patches and circles may be present. They do not 
itch. They are irregularly distributed, and of various 
forms. There may be few or many patches so that the 
skin looks marbled. The circinate patches are more 
common than the macular. They may be 24 cm. in 
diameter, the rings being complete or broken. The 
macules may change into rings. The lesions may dis- 
appear to relapse, or be permanent. They are located 
most often on the trunk, but are not rare on the limbs. 
The face is spared. The general symptoms are those of 
the disease of which they are only the cutaneous mani- 
festations. 

Tubercula Sebacea. — See Milium. 

Tuberculosis Cutis Vera. — Synonyms: T. ulcerosa; 
Miliary tuberculosis of the skin; T. cutis orificialis. 

Symptoms. — This is a rare disease, having been met 
with by Cbiari but 5 times in between 3000 and 4000 
post-mortems of those who had died of tuberculosis. It 
occurs almost exclusively about the mucous orifices — 
mouth, anus, vulva, and glans penis. Crocker describes 
the disease as follows: "The lesions consist of one or 
more discrete, shallow, not painful ulcers, which form 
apparently spontaneously, have an irregular, eroded, 
moderately infiltrated edge, and when the crusts, which 
soon cover them, are removed, show a reddish-yellow, 
granular surface, with a thin, scanty secretion. They 
never heal, but spread slowly and continuously, and may 
coalesce with neighboring ulcers, becoming serpiginous; 
they may thus extend over an area of one or more square 
inches; but, as a rule, they are small. When on mucous 
membranes, yellow miliary papules exist near them." 
They are due to local infection with the tubercle bacillus, 
and are a part of a general tuberculosis. Their diag- 
nosis is difficult, though their nature may be suspected 
on account of the other and evident symptoms of the 
primary disease. 



TUBERCULOSIS VERRUCOSA CUTIS 



707 



Fig. 110 



Treatment. — Treatment is unavailing, though iodol, 
iodoform, or aristol may be applied. 

Tuberculosis Verrucosa Cutis. — Synonyms: Verruca 
necrogenica; Lupus verrucosus; Scrofuloderma verruco- 
sum; (Fr.) Lupus sclereux, ou 1. papillaire verruqueux; 
Anatomical tubercle; Postmortem warts. 

These names have been given by different writers to 
what may be regarded as simply varying aspects of the 
disease described by Riehl and Paltauf 1 as tuberculosis 
verrucosa cutis. 

Symptoms. 2 — The disease oc- 
curs usually in the form of a 
single round or oval patch. 
There may be several such 
patches. If two patches join, 
irregularly shaped patches, with 
scalloped border, may form, and 
perhaps become serpiginous. In 
size the single patches vary 
from that of a lentil up to that 
of a silver half-dollar. Around 
the patch is a narrow zone of 
erythema, of a bright red, that 
disappears under pressure. Its 
surface is smooth, and often 
more shiny than the normal 
skin. Toward the next zone 
it is slightly elevated. Its fol- 
licular openings are preserved. 

Inside of this zone is a row of small, discrete, super- 
ficial pustules, whose covers are so thin that they break 
easily, and we find only the crusts and scales left by them. 
The color of this zone is brown or livid red, and it can- 
not be pressed out entirely, showing that there is some 




Tuberculosis verrucosa cutis. 
(After Hyde.) 



1 Vierteljahr. f. Derm. u. Syph., 1886, xiii, 19. 

2 The description here given is taken, for the most part, from the 
above-mentioned article by Riehl and Paltauf. 



708 DISEASES OF THE SKIN 

infiltration of the skin. This zone is slightly raised, but 
the one to its inner side is markedly so. It has also an 
irregularly knobby surface, becoming distinctly warty 
toward the centre of the growth, the warts being rounded 
or pointed. The nearer the centre the warts are the 
larger they are, some of them being 5 to 7 mm. long. 
The whole surface of this zone is more or less scaly or 
crusted. The color is brownish red. The warty growths 
are often close together with fissures between them, and 
little erosions and pustules. If the patch is pinched up 
between the fingers, little drops of pus may be made to 
well up from between the papillse. The mouths of the 
follicles are destroyed. In some cases acute inflammation 
may occur, and the patch will swell up and become more 
angry-looking. 

After a time the patch begins to flatten in the middle 
by the disappearance of the warty growths, and at last 
becomes changed into a smooth or slightly scaling cica- 
trix, which is thin and soft, with a delicate sieve- or 
net-like appearance. 

The patch is always freely movable upon the under- 
lying parts, and usually gives rise to no subjective symp- 
toms. Sometimes pain is complained of on pressure. 
The growth is by the addition of new lesions on the 
periphery of the old patch, and is usually very slow, and 
at intervals with pauses between. It is a chronic affec- 
tion, showing no tendency to spontaneous recovery. 

Such is the typical disease and its course. In the 
description of the different diseases named above will be 
found some deviations from the type, but they all agree 
in the main, and are probably all one and the same dis- 
ease. It is met with most often upon the back of the 
hands and fingers, but may occur anywhere. 

Etiology. — The cause of this form of tuberculosis is 
the inoculation of the skin with the tubercle bacillus, 
which has been found in sections taken from the patches. 
The disease is seen most frequently in men, and is spe- 
cially prevalent in butchers and those who have to do 



MULTIPLE, ITCHING TUMORS 709 

with animals, such as hostlers and drovers. Dead-house 
attendants are also its victims not infrequently. Cases 
have been directly traced to inoculation with tubercular 
tissue. 

Pathology. — The chief histological distinction between 
this form and lupus, is that w T hile in the latter the foci of 
granulation tissue lie in the lower and middle portions of 
the corium, in tuberculosis cutis they are quite constantly 
found in the papillse and upper papillary layer. 

Moreover in tuberculosis cutis miliary abscesses, due 
to the secondary invasion of the pus cocci, occur imme- 
diatley below the rete. Tubercle bacilli may be scarce 
or plentiful. 

Diagnosis. — Though allied to lupus, it differs from it 
in the entire absence of the characteristic lupus tubercles, 
and of the tendency to ulceration; in the manner of heal- 
ing in the centre by a scar in which no relapse takes 
place; in its superficial situation in the skin; in the 
purulent matter that can be squeezed out from between 
its papillse ; and in the relatively late time of life at which 
it appears. From syphilis it differs in its more chronic 
course; in the absence of a wall of infiltration about it; 
in its color, and in showing no tendency to break down 
and ulcerate. 

Treatment. — The growth may be curetted away, and 
the wound afterward treated with pyrogallol, as in lupus. 
Or it may be destroyed by the galvano-cautery or by elec- 
trolysis. Or it may be covered with 25 per cent, salicylic- 
acid-creosote plaster. Crocker advises the use of this 
plaster, to be followed with the fuming nitrate of mercury 
applied with a piece of wood. I have found the plaster 
sufficient in itself. It must be destroyed entirely or it 
will crop out again. Radiotherapy is indicated. 

Prognosis. — The disease is more easily curable than is 
lupus, and, as a rule, the growths are readily removed. 

Tumors, Multiple, Associated with Itching. — See Lichen 
obtusus and Lichenification. 



710 DISEASES OF THE SKIN 

Tyloma seu Tylosis. —See Keratosis palmaris et 
plantaris. 

Ulcers. — Ulceration is a symptom common to many dis- 
eases, such as lupus, syphilis, serofulodermata, and other 
destructive processes. For these the reader is referred to 
the sections treating of the disease of which they form a 
part. We shall here deal briefly with those ulcers of the 
leg that form so large a part of every dermatological 
clinic and are usually called varicose ulcers. They are 
located most often over the anterior surface of the leg 
and on its lower half. They may he superficial or deep. 
They are irregular in shape with sloping or undermined 
edges, and with a more or less wide zone of redness and 
infiltration of the skin about them. Their bases may be 
covered wit}) flabby granulations; or be smooth and glazed, 
with thin, scanty secretion; or they may discharge a great 
deal of seropurulent matter. Some of them bleed 
n adily, some do not. There may be but one ulcer, or 
there may be several of them. One or both legs may be 
affected. The ulcers may be small, or so large as to encircle 
the leg and occupy more than half its length, and they 
may attain this size either by gradual extension of them- 
selves or by the junction of several ulcers. They begin 
not infrequently as a number of small shelving ulcers on a 
red and densely infiltrated base. These enlarge rapidly 
and form a large ulcer. The patient complains of more or 
less spontaneous pain, and the ulcers an, often very tender. 
The foot arid leg are sometimes greatly swollen and feel 
brawny. It will be noted that the foot and leg are marked 
with dilated veins, and varicosities can be felt sometimes 
like whip-cords under the skin. The deep veins are gen- 
erally swollen at the same time, though they cannot be 
felt so readily. Usually both legs are affected. 

ETIOLOGY. — These ulcers are predisposed to by stand- 
ing for hours at a time, and it is standing in one position 
that is particularly obnoxious. It is therefore in car- 
drivers, blacksmiths, cooks, and those following similar 



UH 711 

occupation- that ulcerations are prone to occur. A loaded 
condition of the portal circulation and constipated I 
als favor vari sities and the occurrence of ulc-er ati 
On account of the chronic. xmgest nditi : the leg. 

some slight traumatism that in the normal state would 
produce hardly appreciable damage will be followed by a 
breaking down of the tissues and an ul 

Diagnosis. — It is most important to diagnose a vari a 
ulcer from one due to syphilis, as they require different 
treatment, and have a dine rent prognosis. The syphilitic 
ulcer is usually located upon the upper half of the leg 
toward its posterior surface, : i ut the knee. It has an 
infiltrated border, but by no mean- as broad a one as the 
varicose ulcer. It lacks the marked inflammatory sym] - 
toms of the varicose ulcer, and is "punched-out looking" 
with perpendicular edges. It is round, or. if formed by 
the coalition of several softened tubercles, it will have a 
scallop Ige, indicating its origin from several distinct 
lesions. As a rule, it is quite painless, and th - ■"-::;-."_ 

ulcers on one leg, the other being B 

Treatment. — I: we can confine our patient absolutely 
to bed, and keep the leg snugly and evenly bandaged, the 
s will heal under simple dressings. This we cannot 
do with most of our cases. Bandaging the leg from the 
I - to the knee is an essential in their successful ma: _ - 
nient, an ordinary roller-bandage heir.: use I as long as 
any greasy applications are made. In ulcers connected 
with varicose veins, after acute symptoms have subsi 
bandaging from the toes to the knee with a rubber 
age is excellent. So, t .in all ulcers is the continous 
bath with warm water. >r by means of cloths wrung out 
of hot water, frequently renewed and covered with oiled silk. 

One of the oldest and best treatments for ulcers is to 
touch them daily with balsam of Peru and cover them 
with oxide of zinc ointment, or. better, with Lassar"s 
paste. Dry dressings for the ulcer are preferable to 
' applications, and for this we may use iodoform, 
iodol, aristol, subnitrate or subiodide of bismuth, or 



712 DISEASES OF THE SKIN 

dermatol, or any of the antiseptic or stimulating pow- 
ders. If there is an eczema or dermatitis about the 
ulcer, it is requisite to cover the powder and the whole 
patch with some mild or stimulating ointment according 
to the state of the skin. In this case the ulcer must be 
dressed once or twice a day. If there is not much derma- 
titis, we can dispense with the ointment, and dress the leg 
antiseptically and leave it for several days. Applications 
of nitrate of silver may be used to stimulate an atonic 
ulcer or to smooth down exuberant granulations. Strap- 
ping with adhesive plaster is another excellent means 
of treating ulcers upon not very much inflamed bases. 
Skin grafting, according to Thiersch's method, is the 
most prompt and sometimes the only way to cause large 
ulcers to heal. For further surgical treatment of ulcers 
text-books on surgery must be consulted. 

Ulcer, Tropical Phagedenic. — This is an ulcer secondary 
to a lesion of the skin that occurs in the tropics, and is 
marked by rapid extension and gangrenous destruction of 
tissues. It may be mild or malignant in its course. The 
latter eats deeply, involving even the bones. It is probable 
that closer study would show that all such ulcers should 
be placed under the diseases of which they form a part, 
such as yaws, syphilis, etc. 

Ulerythema. — This is a name proposed by Unna for 
those diseases in which there is a more or less persistent 
erythema upon which follows cicatrization by a process of 
absorption of inflammatory infiltration, and without 
ulceration. Under this heading comes lupus erythe- 
matosus. Ulerythema sycosiforme is a very severe form 
of sycosis in which little vesicopustules occur at the 
mouths of the hair follicles forming crusted patches. 
When the acuteness of the disease is passed the patches 
are left red and scaly, the skin is cicatricial and the hair 
permanently destroyed. There may be one or many 
patches, and the disease may invade the temporal regions 
of the scalp. 



ULERYTHEMA 



713 



Ulerythema ophyrogenes according to Taenzer 1 begins 
in infancy and lasts through life. It affects the eye- 
brows as a hyperkeratosis and redness of the outer end. 
There is a more or less complete stopping up of the hair 
follicles. In the mild form the process may extend to 



Fig. Ill 




Lupoid sycosis. (Rainforth.) 

the ears and down the neck and arms. In the severe 
form the whole of the eyebrows is affected, as well as 
the upper lip, and scalp. It causes destruction of the 
skin, and on the scalp it may completely destroy the hair. 

1 Monatshft. f. prt. Dcrmat., 1889, viii, 187. 



714 DISEASES OF THE SKIN 

The disease is indolent in its course, and intractable 
to treatment. It bears a resemblance to "folliculitis 
decalvans." 

Ulerythema acneiforme is the name given by Unna 1 to 
a purely local, probably parasitic, disease of the skin 
which is limited to the neighborhood of individual hair 
follicles. It begins as an inflammatory erythema, which, 
after persisting for some time, leads either to the forma- 
tion of a well marked cornification of the cuticle and 
comedones, or to cicatricial atrophy. 

It differs from acne in beginning on the middle of the 
cheek and margin of the auricle; in extending to the 
hairy scalp; in being primarily an inflammatory ery- 
thema; in an absence of suppuration, and in atrophy 
occurring without suppuration. It differs from acne 
necrotica in complete absence of necrosis, suppuration, and 
ulceration; in prominence of comedones, and in having 
no resemblance to variola in its scar. 

Uncinarial Dermatitis, or ground itch, is due to the 
invasion of the skin by nectator Americanus or hook 
worm which lives in the mud in some tropical countries. 
It attacks those who go bare footed. It causes itching, 
followed by redness and swelling, papules, and vesicles. 
In bad cases pustulation may take place, and extensive 
ulceration leaving scars. In mild cases the dermatitis 
subsides in one or two weeks. Systemic infection may 
take place marked by prostration, pains in the epigas- 
trium, shortness of breath, palpitation, and fever. It 
may cause death with symptoms of profound anemia. 
The treatment of the dermatitis is by alsolute cleanliness, 
and soaking the feet in a saturated solution of boric acid, 
or a weak solution of bichloride of mercury. 

Uridrosis or Sudor Urinosis. — By this is meant the 
excretion by the sweat pores of sweat loaded with the 
constituents of the urine, specially urea. The sweat then 

1 Internat. Atlas of Rare Skin Diseases, No. 1. 



URTICARIA 715 

often has a urinary odor, and deposits crystals of urates 
upon the skin. It is usually met with in severe renal 
disease where there is suppression of urine. 

Urticaria. — Synonyms: Cnidosis; (Fr.) Urticaire; (Ger. 
Nesselsucht, Nesselausschlag, Porcellanfriesel; (Eng.) Net- 
tlerash, Hives. 

An acute or chronic disease of the skin characterized 
by the appearance of wheals. It may run an acute or 
chronic course. 

Symptoms. — The vast majority of cases run an acute 
course. The characteristic feature of the disease is the 
appearance of wheals — that is, firm, flat, circumscribed 
elevations of the skin which are at first pink, and then 
white. They may remain pink. They may be round, 
oval, annular, or elongated, and are always surrounded 
by a red areola. They vary in size, sometimes being no 
larger than the head of a pin, papular urticaria, and some- 
times of the diameter of an inch. They show no tendency 
to group, but are irregularly disseminated over the 
whole body. Though they are not symmetrical in dis- 
tribution, both sides of the body are affected at the same 
time, and they show some preference for the extensor 
surfaces of the arms and legs. They itch, burn, and 
tingle, and are always scratched. They are ephemeral, 
each lesion lasting but a short time — from a few minutes 
to a day. Exceptionally some wheals will last several 
days. New lesions crop out as old lesions fade, and thus 
the eruption is continued. The mucous membranes are 
often affected at the same time with the skin; and if the 
pharynx is attacked there may be suffocative symptoms. 
The duration of the disease as commonly met with is but 
a few days, and not infrequently the wheals may be 
entirely absent during the day, to break out again at 
night. Very often when the patient is seen by the phy- 
sician, he can find nothing but scratched papules. But 
the patient will tell him that when he is undressing, or is 
warm in bed, the itching becomes unbearable, and lumps 



716 DISEASES OF THE SKIN 

looking like mosquito-bites break out upon him. The 
skin of a patient with urticaria is very irritable, so that 
a sharp tap upon it or drawing the nail across it will 
produce a wheal. 

The outbreak of the disease may be sudden without 
constitutional disturbance, or there may be some burning 
and tingling of the skin before its appearance. Or there 
may be some febrile movement, and some evident dis- 
turbance of the digestion, such as vomiting or dyspeptic 
symptoms. When the disease is cured the lesions dis- 
appear without desquamation, and leave no trace. Such 
is the acute form. 

Chronic urticaria differs from the acute form mainly 
in its duration. Instead of recovery taking place in a 
few days or weeks, its course is one of months and years. 
Sometimes the outbreaks of the eruption show marked 
periodicity, occurring at stated intervals after pauses of 
complete immunity. The eruption is generally not so 
extensive in the chronic as in the acute form. If the 
itching has been very severe and the scratching propor- 
tionally excessive, the skin may become pigmented, as in 
other chronic pruritic diseases. 

The wheals assume different appearances in different 
cases, and different adjectives are used to express the 
varying pictures. It is not necessary to burden the 
mind with these, though they are convenient for descrip- 
tive purposes. Thus we have urticaria tuberosa seu 
gigans, where the lesions are unusually large; urticaria 
bullosa, where the wheals are surmounted by bullae; 
urticaria hemorrhagica, where hemorrhage into the 
wheals occurs; urticaria wdematosa, probably the same 
as acute circumscribed oedema or acute angioneurotic 
oedema, where the wheal occurs in locations in which the 
subcutaneous tissues are lax, as about the eye, nearly 
closing it, or on the tongue, causing it to swell enorm- 
ously and threaten suffocation; urticaria papulosa, or 
lichen urticatus, where the wheals are small, a form com- 
mon about the buttocks of children. 



URTICARIA 717 

Urticaria factitia is the name used to express the fact 
that, on account of the irritability of the skin, a wheal 
may readily be excited by local irritation. Urticaria 
yerstans simply refers to the persistent character of the 
single lesion. Urticaria maculosa is the name proposed 
by Fournier for that form in which the wheal remains 
red. 

Etiology. — The causes of the disease are more numer- 
ous than the forms it may assume. Most of the acute 
and many of the chronic cases are dependent upon irri- 
tating ingesta, such as shell-fish, strawberries, cheese, 
pickles, mushrooms, pork, sausages, even mutton in some, 
and almost anything in other people, it being largely a 
matter of idiosyncrasy; medicinal substances, such as 
quinin, cubebs, copaiba, salicylic acid, opium, and other 
drugs. The rupture of hydatid cysts has been followed 
by urticaria. Dyspepsia in its various forms, and con- 
stipation, are common factors, especially in chronic urti- 
caria, as are intestinal worms in children. So also at 
times may be disorders of the liver, uterus, and ovaries. 
Some very severe cases occur during pregnancy. Some 
cases seem to be purely emotional in origin. Gout, rheu- 
matism, malaria, and functional or organic diseases of 
the nervous system will be found at the bottom of many 
cases of chronic urticaria. Wright holds that diminu- 
tion in the lime salts in the blood that interferes with its 
coagubility is the cause. 

Not only do we have internal causes producing the 
disease, but also external causes, such as contact with the 
jelly-fish; crawling of caterpillars over the skin; the action 
of cold, or sudden changes of temperature; the galvanic 
current and bites of insects. Urticaria is a common 
accompaniment of scabies and pediculosis. 

Pathology. — Urticaria is due to a vasomotor dis- 
turbance. At first there occurs a spasmodic contraction 
of the vessels of a circumscribed area of the skin, which 
is followed by paralytic dilatation of the vessels and 
retardation of the circulation. Serous exudation ensues, 



718 DISEASES OF THE SKIN 

forming the wheal, which at first is pink, and then be- 
comes white, on account of the pressure of the fluid forc- 
ing out the blood from the central parts of the wheal. 
When the paresis ceases, the serous exudation is ab- 
sorbed and the part returns to its normal condition. 
T. C. Gilchrist, 1 Torok, and others do not believe in the 
vasomotor theory of the disease, but think that it is an 
inflammation of the skin, due to the escape of some 
toxin from the blood into the derma. J. Baum 2 has pro- 
duced wheals experimentally in frogs. He found that 
the capillaries dilate and fill with blood, the arteries 
dilate slightly and the veins more. The circulation 
gradually becomes slower, until stasis occurs at the 
periphery of the wheal. In ten to twenty minutes the 
wheal appears on account of oedema of the part. 

Diagnosis. — The occurrence of wheals is pathogno- 
monic of urticaria, as they occur in no other disease. 
When they are present there is no difficulty in diagnosis. 
When they are not present and we find only scratch 
marks we have to decide whether we have to do with 
urticaria or eczema, scabies, pediculosis, or dermatitis 
herpetiformis. Eczema differs from urticaria in the 
tendency its lesions have to run together and form 
patches. It never could be so generally distributed 
without presenting some characteristic patches. Scabies 
shows scratch-marks on the hands and feet, between the 
fingers and toes, in the axillae, about the umbilicus, and 
on the breasts of the female and the penis of the male. 
The cuniculi may be found in most cases. Pediculosis 
shows long parallel scratch marks over the back, between 
the shoulders, along the outside and inside of the limbs 
where the seams of the clothing come, and about the 
waist. Dermatitis herpetiformis presents grouped lesions, 
which usually are vesicles, but may be papules. Ery- 
thema of papular or tubercular variety may resemble 

1 Jour. Amer. Med. Assoc, 1896, xxvii, 1222. 

2 Berlin, klin. Woch., 1905, xlii, 9. 



URTICARIA 719 

urticaria, but it is a markedly symmetrical disease, and 
burns rather than itches. 

Treatment. — In acute urticaria the administration 
of a prompt cathartic or saline laxative will usually cure 
the disease if due to some irritating ingesta. Emetics 
may be useful, if we see the case before stomachic diges- 
tion is ended, but in most cases we are called in when it 
is too late for them to be of service. Saline laxatives, 
mineral acids, the rhubarb and soda mixture, salol, 
resorcin, creosote or other intestinal disinfectants are of 
service in the more chronic cases. Of course, if the 
eruption is due to the ingestion of drugs, they must be 
stopped. 

In chronic cases, besides medicinal treatment we must 
regulate the diet, studying each case by itself. It is 
often well to put the patient on a strictly milk diet for a 
few days, and then add other articles with care. Alco- 
holics in all forms, and especially beer or other malt 
liquors, should be prohibited. If the gouty or rheumatic 
diathesis is at the foundation of the trouble, it must be 
combated. If the outbreak shows marked periodicity, 
sulphate of quinin may do good. Salicylate of soda 
salicin, and salol and alkaline diuretics and laxatives 
sometimes do good service even when there is no evident 
rheumatic tendency. In fact, we must endeavor in 
every way to get our patient into a normal state of 
health. Ravitch 1 regards thyroid extract as a specific. 
Whitfield advises giving calcium lactate. The most 
difficult class of cases are those in which a neurosis alone 
seems to be the cause. Then belladonna, atropia, arsenic, 
the bromides, antipyrin, phenacetin, and galvanism may 
be tried. Pilocarpin, wine of antimony, colchicum, ergot, 
are also commended. It may be necessary to procure 
sleep in some cases by giving bromides, sulphonal, and 
the like. Opium is to be avoided. In very obstinate 
cases the patient should be sent away from home and . 
relieved from all business cares. 

1 Jour. Cutan. Dis., 1907, xxv. 512. 



720 DISEASES OF THE SKIN 

In the urticaria of pregnancy Linser 1 has had remark- 
able results from the injection of serum taken from 
another pregnant woman. The directions for giving the 
serum will be found in the section on pruritus cutaneous. 

Local Treatment is of great service in allaying the 
itching, but it will not cure the disease. The parts may 
be sponged with alkaline lotions, such as a teaspoonful of 
baking-soda to a hand-basinful of water. Sometimes 
more relief is obtained by an acid solution, such as vinegar 
pure or with water. Carbolic acid in vaselin, or alcohol 
and water, is sometimes very efficacious. In vaselin, 10 
per cent, strength is sufficient; in lotion form we may use, 
to the adult skin, 1 to 2 (4 to 8) drachms to the ounce 
(32) directing the patient to dab and not rub it on the 
skin. Hardaway prefers using the acid in a spray, 2 to 4 
(8 to 16) drachms to the pint (500), with 1 ounce (32) of 
glycerin. To each atomizerful 10 drops of oil of pepper- 
mint may be added to increase its antipruritic qualities. 
Menthol, 1 to 10 per cent, in alcohol or almond oil, is 
said to be efficacious. Crocker speaks highly of liquor 
carbonis deter gens, 3j togiv (4 to 120); terbene, oivtogiv 
(16-120); and equal parts of sanitas and water. Salicylic 
acid, 20 grains (1.33) to the ounce (32) of castor oil, is 
good, but disagreeable. Camphor and chloral hydrate, each 
from J to 1 drachm (2 to 4), rubbed together and added 
to 1 ounce (32) of starch or ungt. simplex, is another 
good antipruritic. Chloroform dabbed or sprayed on 
renders prompt relief. Baths are sometimes of use. 
Having the patient take a warm bath containing either 2 
to 6 pounds of bran, or a J to J a pound of bicarbonate 
of soda, or an ounce of nitromuriatic acid, just before 
going to bed; then drying the skin by wrapping in a 
warm sheet and patting the skin dry; then smearing the 
skin with a film of vaselin and dredging over this corn 
starch powder, will often give him a good night's rest. 

Prognosis. — The vast majority of cases of urticaria 
recover in a few hours or days. The chronic cases often 

i Dermat. Woch., 1912, liv, 365. 



URTICARIA PIGMENTOSA 721 

are most obstinate, but unless some severe nerve lesion is 
at the bottom of the case, they can be cured by patient 
and perservering effort. When occurring in the course of 
pregnancy, premature delivery may have to be induced 
to relieve the woman of her suffering. 

Urticaria Pigmentosa. — Synonym: Xanthelasmoidea. 
U. perstans pigmentosa. 

This is not an ordinary urticaria, that, on account 
of its chronic course and the scratching to which it has 
been subjected, leaves more or less pigmentation of the 
skin. Such a condition of things is not infrequently 
seen. Urticaria pigmentosa begins within the first six 
months of life by an eruption of wheals or tubercles, which 
at first are about the size of a split-pea, and of a brownish 
or yellowish-red color, with a pink areola. Later they 
may increase in size, or several may coalesce to form a 
large one, and assume a yellow or buff color. These 
wheals appear in crops, and run a very chronic course, 
each one persisting for weeks or months. Then they 
shrink, become softened, and disappear, leaving brownish 
pigmentation. As the course is chronic, we will find on 
the patient wheals or tubercles of red or yellow color, of 
various sizes, some hard and tense, some soft and wrinkled, 
and brown stains of the skin. Ordinary urticarial evanes- 
cent wheals will sometimes be found, and rubbing of the 
apparently stationary tubercles will cause some of them 
to enlarge. The wheals are most often located on the 
trunk and neck; then on the limbs, face, and head; but 
they may appear on any part of the body surface as well 
as on the mucous membranes of the mouth and pharynx. 
Itching is usually present, but may be absent. After a 
number of years the wheals will no longer come out, and 
recovery is generally complete at about the age of puberty, 
though the disease may last much longer than that. 
Morrow 1 has reported one case of over twenty years' 

1 Jour. Cut an. and Gen.-Urin. Dis., 1895. viii, 445. 
46 



722 DISEASES OF THE SKIN 

duration. The majority of the cases, according to Crocker, 
occur in boys. We know no cause for the disease. 

Histologically, the characteristic feature, beside the 
oedema and deposit of pigment in the epidermis, is the 
cellular infiltration of the upper derma composed chiefly 
of mast cells. In this disease, even in the healthy skin, 
the number of mast cells is remarkably increased. 

Thus far treatment has been in vain. It is esentially 
the same as in chronic urticaria. One case was cured 
by Torok and Schein 1 by the x-rays, used to the pro- 
duction of a dermatitis. 

Vaccinal Eruptions. — The eruptions that accompany or 
follow vaccination may be local, starting from the point of 
inoculation; or general, and due to the absorption of the 
virus, which in some subjects acts as do medicinal sub- 
stances in other people. The majority of them are due 
not to any bad quality of the virus, but either to some 
accidental infection or to idiosyncrasy. Sometimes an 
ulcer will form at the site of the vaccination; or starting 
from this point we may have a dermatitis, cellulitis, 
lymphangitis, erysipelas, abscess, or furuncle. At times 
exuberant granulations, or what is called an infective 
granuloma, may develop upon the seat of the vaccination. 
An outbreak of impetigo contagiosa may originate from 
inoculation, the pus of the sore becoming transferred to 
other parts by the finger nails; or an eczema or psoriasis 
may be set up by the irritation of the sore, just as they 
may follow other affections of the skin. 

General eruptions usually appear, according to Harda- 
way, after the ninth or tenth day of vaccinia, and assume 
an erythematous, papular, or papulovesicular character. 
The roseola vaccina of Hebra is an erythematous eruption 
of macular character, commencing usually upon the 
arms, and sometimes spreading over the whole body. It 
is accompanied in some cases with slight rise of tem- 
perature for a few hours. It disappears and leaves no 
trace. 

i Wien. med. Woch., 1902, liii, 847. 





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Ev * - -' * ■* ^ 


*i 


%'fi : 



a 
in 



2. ° 

3 



PQ 



VARIOLA 723 

We may also encounter erythema multiforme and urti- 
caria complicating vaccination. It is possible that a bul- 
lous eruption may occur, but this is very rare. Syphilis 
also may be inoculated in arm-to-arm vaccination. Gan- 
grene may occur in the sore and other accidents. All of 
these are rare. 

Varicella, or Chicken-pox, is an eruptive fever of mild 
grade, with an incubative period of two weeks. It is 
characterized by an outbreak of a greater or less number 
of transient red papules and clear vesicles, of pinhead to 
pea size, and varying shape, that come out in crops. Later 
they may become pustules. A long vesicle is very char- 
acteristic of this eruption, as is the location of the vesicle 
or pustule to one side of the areola. The eruption is 
usually scanty. Umbilication occurs in some of the vesi- 
cles. The vesicle can be easily ruptured. There is usually 
only slight constitutional disturbance. The mucous mem- 
branes may be involved. In the early stages there is 
possibility of taking the disease for variola. It is differen- 
tiated from it by the mildness of its symptoms, the finding 
of lesions in all stages, the ease with which the vesicles 
may be ruptured, the infrequence of umbilication and the 
rapid course it runs. Treatment is purely expectant. 

Variola, or Smallpox, is an acute contagious fever with 
an incubative period of about two weeks. It is charac- 
terized by very severe prodromal symptoms, such as 
a chill with fever, of 103°, vomiting, headache, and 
intense pain in the back and legs, and the appearance, 
usually on the third day, of an eruption of minute red 
spots that in twenty-four hours change into small, round, 
hard, shotty papules. The eruption is first seen on the 
face about the forehead and mouth and on the neck 
and wrists. In about three days vesicles form upon the 
papules, and attain their full development by about their 
fifth day. They then are umbilicated, are located upon 
a hard base, and have a well-marked areola. Now they 
change into pustules, and a well-marked secondary 



724 DISEASES OF THE SKIN 

fever attends the change. After about four or five days 
the pustules dry up into crusts, and afterward these fall, 
leaving pitted cicatrices in many places. In regular 
cases it takes three or four weeks for complete shedding 
of the crusts, making the entire duration of the disease 
from five to six weeks. Severe types of the disease are 
known as confluent and hemorrhagic variola, and are 
marked by more severe symptoms and complications. The 
mucous membranes are commonly involved. In varioloid, 
modified smallpox, the constitutional symptoms as well 
as the eruption are of much milder grade. 

Diagnosis. — Variola bears a resemblance to the pus- 
tular syphilide; for the differential diagnosis, see the 
" pustular syphilide. " Acne and pustular eczema both 
have lesions resembling those of variola, but are limited 
to certain regions, and are not general eruptions. Vari- 
cella and papular erythema have been mistaken for 
variola. In its earlier stages the diagnosis of variola is 
very difficult. In pronounced cases, on the other hand, 
the diagnosis is easy. For the diagnosis from varicella 
see varicella. 

Veld Sore. — According to Crocker, this is a disease met 
with in South Africa. The sores occur most often on the 
hands and forearms, feet, and legs. They begin as itch- 
ing pinhead papules, vesicles, or pustules, which rapidly 
increase in size. They rupture readily and form painful 
dirty-looking sores, covered with a crust exuding pus and 
serum. There is often a lymphangitis and enlargement 
of the lymph glands. Sometimes it may take the form 
of a huge flat pustule covering the whole of the back of 
the hand. Cultures show a coccus resembling staphylo- 
coccus aureus. It may be only a form of tropical im- 
petigo contagiosa or ecthyma. Horseflies are accused as 
being the distributing agent. The treatment is by means 
of antiseptic dressings. 

Verruca. — Synonyms: (Ft.) Verrue; (Ger.) Warze; 
Wart. 



VERRUCA 



725 



These exceedingly common papillary outgrowths assume 
various appearances, to which descriptive names have 
been given. Thus we have verruca vulgaris, or the wart 
so often seen on the hands of children and young people. 
These vary in size from that of a hemp-seed to that of a 




Verruca vulgaris. (By the courtesy of T Dr. S. Dana Hubbard.) 



split-pea, or larger where two or more become aggregated. 
They are sessile, hard, conical, with flattened tops. They 
may be smooth, or uneven, showing their papillary for- 
mation. They may be of the color of the skin, or some 
shade of yellow, brown, black, or green. There may be 






726 DISEASES OF THE SKIN 

a number of them, and they may be isolated or aggre- 
gated. They may occur elsewhere than on the hands. 
One variety occurs on the soles of the feet. They look 
like callosities. They are often painful. When the hard 
calloused skin is shaved off the warty character of the 
growth is disclosed. Verruca digitata is a wart in which 
the papilla? are separated distinctly from each other. 
These occur in groups, and are often seen on the scalp. 
Verruca filiformis is a wart in which the papillse are not 
only distinct, but fine, almost thread-like. Each papil- 
lary outgrowth stands by itself. These are soft to the 
touch, and occur on the face, eyelids, and neck. Ver- 
ruca plana is a flat wart, but slightly elevated, and vary- 
ing in size from that of a pinhead to a half -inch in dia- 
meter. These sometimes occur in large numbers. In 
young people they occur upon the face and backs of the 
hands, and may or may not be pigmented. In old people 
they occur on the trunk and arms and are pigmented, 
and are called verruca senilis or seborrheal warts. Ver- 
ruca acuminata, also called condyloma acuminata, vegeta- 
tion dermique, spitzen warzen, and venereal or moist wart, 
is met with in the anal and genital regions of both sexes, 
as also in the axillse, under the hanging breasts, in the 
umbilicus, and between the toes. These are vascular, 
sessile or pedunculated, and composed of a great number 
of closely aggregated projections of various shapes. On 
exposed situations they are dry and of the color of the 
skin; while in locations that are moist — that is, between 
the skin-folds — they are covered with a whitish puriform 
secretion, and, unless kept very clean, they emit an offen- 
sive odor. They sometimes attain to an immense size. 

Etiology. — We do not know the cause of warts. 
They are contagious, or auto-inoculable at least, and par- 
asites have been isolated and declared to be the morbific 
agents. They have been produced by inoculation. 
Minute particles of glass or iron have been found in 
some warts suggesting that they may be caused by 
traumatism or local irritation. They occur more fre- 



VERRUCA 727 

quently in the young than in the old, and may be con- 
genital. Venereal warts are traceable to irritating dis- 
charges, but not by any means always to a gonorrhea. 
They are undoubtedly contagious. 

Pathology. — Warts concern the rete mostly, being 
markedly downward and upward growths of its cells. 
The papillae beneath the wart are flattened. The corneous 
layer of the skin is hypertrophied, but less compact than 
normal. Verrucse acuminata? differ from other warts in 
the absence of any anomalies of keratinization, and in the 
excessive development of the rete, marked papillary 
enlargement and abundant vascular supply. 

Treatment. — The treatment of most all warts is 
prompt and efficient by means of the curette, scraping 
them off while the skin is slightly stretched. If there is 
any doubt about their returning, their bases may be 
touched with iodine or nitric acid. Generally simple 
scraping is sufficient. The wart often is thus turned out 
of the skin entire, like a pea from a pod. No scar is left, 
because the corium is not wounded. Electrolysis may be 
used. The digitate and filiform warts may be snipped 
off with the scissors. If operative interference is refused, 
the warts may be removed by painting with tincture of 
iodine; or a saturated solution of salicylic acid in collodion ; 
or a 20 per cent, solution of resorcin; tincture of thuja; 
or nitric or trichloracetic acid. G. W. Fitz 1 says that paint- 
ing them daily with a 10 per cent, solution of chrysarobin 
in traumaticin, after rubbing them down with fine sand- 
paper, will remove them in a week or so. In the country 
children's warts are removable in some cases by the appli- 
cation of the juice of the common milk-weed. Chromic 
acid is a powerful caustic. Caustic potash is not a safe 
agent to use, unless care is had to limit its action by a ring 
of wax about the wart. The galvanocautery may also be 
employed, as well as x-rays and carbonic dioxid snow. 
Sparking with the high-frequency current is also a good 
method of treatment. 

1 Boston Med. and Surg. Jour., 1899, cxl, No. 26. 



728 DISEASES OF THE SKIN 

Venereal warts may be removed by keeping them clean 
and dry, and painting them with liq. plumbi subacetatis, 
or a solution of the per chloride or persulphate of iron; or 
dusting them with salicylic acid and starch, or with boric 
acid. 

It is said that warts may be removed by internal treat- 
ment. Sulphate of magnesia, 2 to 3 (0.12 to 0.18) grains 
to a child and J a drachm (2) to an adult, three times a 
day, is one remedy. Besnier has tried this method in a 
number of cases with absolute unsuccess. Tincture of 
thuja occidentalis is said to be efficacious. Crocker thinks 
he has seen cures effected with full doses of nitromuriatic 
acid, while others advocate arsenic. J. B. Cooper 1 claims 
to cure warts in from four to six weeks by giving a wine 
glass of lime water in a little milk after the noon day meal. 
C. Watson 2 has cured a case of multiple warts by giving 
a J ounce of castor oil twice during the first week, and 
once a week afterward. We have tried this without 
success. 

Warts very often disappear of themselves and no one 
has ever seen them fall. 

Verrue. — See Verruca. 

Verruga Peruana. — This disease is said to occur in the 
narrow, hot valleys of Peru. It begins as a fever resem- 
bling malaria, accompanied by anemia, pains in the joints, 
neuralgia, and swelling of the liver and spleen. The 
patient may die in this stage. If he survives, the warts 
follow the fever. They may appear suddenly without the 
prodromal fever. They may be miliary in size, and rosy 
and translucent; or larger, forming dull, horny papules; or 
nodular in size, when they may be complicated with fur- 
uncles. They may come out in groups and run together. 
They are scattered over the body. They may undergo 
spontaneous involution. When in groups, they may 
break down and ulcerate. A special bacillus is supposed 

1 Brit. Med. Jour., 1905, ii, 441. 

2 Brit, Jour. Dermat., 1903, xv, 178. 



VITILIGO 



729 



to be the cause of the disease. They are to be scraped 
off with a curette, and the patient is to be removed 
from the endemic area and given large doses of the 
chloride of iron, and of quinine. 



Fig. 113 




Leukoderma. (By the courtesy of Dr. S. Dana Hubbard. J 



Vitiligo. — Synonyms: Leucoderma; Leucasmus; Leu- 
copathia; Achroma; Piebald skin. 

An acquired loss of pigment of the skin characterized 
by the formation of symmetrical white patches with con- 
vex borders surrounded by an area of hyperpigmentation. 

Symptoms. — This is an acquired anomaly of pigmen- 
tation, the opposite to chloasma. It is akin to albinismus, 
only that the latter is a congenital condition. It consists 
in the disappearance of the pigment of the skin in circum- 
scribed round or oval patches so that white areas are 



730 



DISEASES OF THE SKIN 



Fig. 114 



formed. At the same time there is an accumulation of 

pigment around the areas, so that there is at once a process 

of apigmentation and of hyper- 
pigmentation. The size of the 
patches varies greatly. They 
may be no larger than a ten-cent 
piece or of immense size. The 
disease most commonly begins 
upon the neck, face, or backs of 
the hands, but may begin any- 
where. It is chronic. It may 
progress so as eventually to in- 
volve nearly the whole body; or 
it may become stationary; or, 
in rare cases, the skin may be- 
come pigmented again. It is a 
symmetrical disease in nearly all 
cases. The general health is un- 
affected, and there is no change 
in the sensibility of the patches. 
In some cases the white parts 
are unusually sensitive to ex- 
posure to the sun. When the 
scalp or hairy regions are affected 
the hair turns white. The disease 
is most evident in the summer on 
account of the increased pigmen- 
tation that normally occurs in 
the sound skin at this season. 

Etiology. — The cause of the 
disease is obscure. All we can 
now say is that it is probably 
a disturbance of innervation. It 
is uncommon for it to occur 
before the tenth year of life, 
though it may do so. Adults are 

most frequently affected. Both sexes are subject to it. 

It seems in some cases to be hereditary. It is assumed 




Leucoderma. (After Hyde.) 



WASH LEATHER SKIN 731 

that it is a neurosis. It is more common in the warm 
than in the cold countries, and is particularly common in 
negroes. Exposure to the sun and cold seems to be an 
excitant in some cases. It has followed typhoid fever, 
scarlatina, and malarial fever. Wood 1 says that when 
mulattoes contract syphilis they become several shades 
lighter all over the body. Symptomatically it is seen 
with morphea, Addison's disease, and alopecia areata. 
There is also a syphilitic vitiligo. 

Diagnosis. — There is little difficulty in diagnosis, as 
there is no other disease in which the only symptom is a 
loss of pigment with a surrounding pigmentation. In 
morphea the patch may be raised, and the skin is changed 
in texture, and there is apt to be a little lilac ring about it. 
In chloasma the patch itself is dark with a convex border, 
while in vitiligo the border of the pigmentation is con- 
cave. The concave border of the pigmentation will 
also distinguish the disease from chromophytosis, which 
is also scaly. The normal sensation of the patches dis- 
tinguishes them from leprosy, in which the patches are 
anesthetic. 

Treatment. — Unfortunately there is hardly anything 
that can be done in the way of treatment. Galvanism or 
faradism may be tried, and nerve tonics given. Thyroid 
extract, or adrenalin may be tried. We must content 
ourselves with making the patches less evident by remov- 
ing the pigment from about them by the means given 
under Chloasma. Or we can stain the patches so that 
they shall be less white, as by the use of walnut juice. 
Besnier and Doyon believe that they have cured cases 
in young subjects by the prolonged use of bromide of 
potassium internally, and saline or bromo-iodide baths 
externally, with or without injections of pilocarpin. 

Wart. — See Verruca. 

Washleather Skin is that condition of the skin in which 
certain metals, specially silver, mark it with a black line. 

1 Jour. Cutan. and Ven. Dis., 1883, i, 274. 



732 DISEASES OF THE SKIN 

It occurs, as a rule, in patients suffering from diseases 
which directly or indirectly affect either the trophic or 
the sensory nerves, such as renal disease, tuberculosis, 
erysipelas, and hemiplegia. It sometimes precedes the 
occurrence of bed-sores. 

Xanthelasma. — See Xanthoma. 

Xanthoma. — Synonyms: Xanthelasma; Vitiligoidea ; 
Molluscum cholesterique ; Fibroma lipomatodes. 

A peculiar disease of the skin characterized by the 
appearance of discrete patches, or tubercles, of chamois 
or lemon-yellow color. 

Symptoms. — Xanthoma may assume one of two forms: 
Xanthoma planum or Xanthoma tuberosum sen tubercu- 
latum. In the former we meet with flat, chamois leather- 
like, or lemon-yellow plates that are either slightly raised 
above the level of the skin or not at all raised. Excep- 
tionally they may be dark yellow, whitish or creamy, or 
deep brown. They vary in size from an eighth of an inch 
to an inch in their long diameter, feel soft and smooth to 
the touch, and when pinched between the fingers no infil- 
tration of the skin is perceptible. They are irregular in 
shape, tending to form elongated figures. When in patches, 
they feel almost velvety, and when examined with a lens 
they often are seen to consist of an aggregation of small 
granules, many of which have a central pinkish punctum. 
They are slow in growth, and when they have attained 
a certain size may remain stationary. The favorite site 
of xanthoma planum is in the upper eyelid, where they 
are not infrequently seen. There they commence at the 
inner canthus, most often of the left eye, and spread in a 
semicircle about the eye, while shortly afterward a similar 
growth begins on the right upper eyelid. They may be 
found also on the lower lid. Next in point of frequency 
to the eyelids, they occur upon the flexures of the joints 
and upon mucous membranes. 

Xanthoma tuberosum exhibits lesions of the same color 
as does the plane variety, or they may be reddish yellow, 



XANTHOMA 733 

but they are raised above the skin, and may attain to a 
large size. They are soft, smooth, round or oval, with 
telangiectases over them when small. When large, they 
are firmer and more irregular in shape, being made up by 
aggregation of a number of smaller tubercles. Xanthoma 
multiplex is the name applied to cases in which both varie- 
ties are present. In all forms, unless there is jaundice, 
the skin between and about the lesions is normal in color. 
Most cases give rise to no subjective symptoms, but there 
may be some itching or burning. If the disease occur 
upon the palms or knees, it may cause discomfort or even 
pain on kneeling or handling objects. 

Xanthoma tuberosum is most frequently seen upon the 
knees, elbows, knuckles, and other points of pressure, the 
trunk being not so much affected. Symmetry is generally 
observed. Xanthoma multiplex is often very widely 
distributed. Sometmes the lesions run in streaks, or, as 
in Hardaway's case, 1 are arranged like a zoster. 

Under the name of Pseudoxanthom elastique E. Bodin 2 
has described an eruption of pinhead-sized, oval or round, 
pale yellow lesions that occurred in symmetrical patches, 
about which were scattered single lesions. The surface 
of the patches was smooth or slightly granular. They 
occurred on the lower part of the abdomen, clavicular 
region, anterior wall of axillae, inside of arm, forearm, 
and thighs. 

The skin in xanthoma is not alone affected. Xantho- 
matous bodies are found in the liver, mucous membranes, 
and tendons. Jaundice is not infrequently met with. 
The disease is progressive for a time, and then may 
remain stationary for years, or may undergo spontaneous 
resolution. 

Etiology. — Xanthoma occurs much more frequently 
in adults than in children, and that form that occurs in 
the eyelids is much more common in women than in men. 
Several cases may be seen in the same family, and the 

1 St. Louis Courier of Med., October, 1884. 

2 Ann. de derm, et de syph., 1900, i, 1073. 



734 DISEASES OF THE SKIN 

disease is sometimes hereditary. But we really do not 
know as yet what is the cause of the disease, though vari- 
ous theories have been advanced. Crocker states that 
four-fifths of the cases of xanthoma multiplex occurring 
after puberty are associated with chronic jaundice. 
Hepatic diseases; diabetes; diathetic conditions of various 
kinds; migraine; embryonic cells left in the skin — each 
have been found in connection with one or many cases. 
Hardaway may not be wrong in his idea that it is a dia- 
thetic disease, and that when it occurs with jaundice it is 
because the same tubercles have been deposited in the 
liver as in the skin, and the jaundice is secondary to 
them. 

Pathology. — It is a connective-tissue new growth 
containing an abundance of fat. Between the connec- 
tive-tissue bundles the so-called "xanthoma cells" are 
found. According to Politzer 1 these are not cells but 
fragmented and degenerated remains of muscle fibres 
with proliferated sarcolemma nuclei. Crocker does not 
accept this, but states that he considers "inflammation 
as the primary feature, and the xanthoma cells and con- 
nective-tissue growth secondary, and the whole process 
of toxemic origin." The color of the lesions is due to 
fat-globules (Heitzmann). 

Diagnosis. — The diagnosis of this unique disease is 
made by the occurrence of chamois-leather-colored soft 
plates or tubercles, such as occur in no other disease. 
Milium may bear some slight resemblance to xanthoma, 
but it is hard and firm, not soft and velvety, and white, 
not yelloAv. It is easily squeezed out after a prick through 
the skin over it, an impossibility in xanthoma. 

Treatment. — The patches may be excised. They may 
be destroyed by electrolysis. As in the operation for 
removal of superfluous hair, the fine steel broach attached 
to the negative pole of the galvanic battery is used, and 
it is passed under the growth from side to side. A series 

1 Jour. Cutan. Dis., 1910, xxviii, 633. 



XANTHOMA DIABETICORUM 735 

of tracks under the growth and parallel to each other are 
made, the current always being completed after the 
needle is in position and broken before the needle is 
removed. A current of 2 or 3 ma. should be used. Besnier 1 
reports good results from the administration of phos- 
phorus in cod-liver oil, giving 1 mg. per day, and increasing 
the dose each day by a J of a mg. until 3 mg. are taken. 
After fifteen days this is stopped and turpentine is given. 
Stern 2 tried this plan without success, but succeeded 
in removing patches of the disease from the eyelids by 
the use of a 10 per cent, solution of corrosive sublimate in 
collodion. Shepherd, of Montreal, saw one case recover 
after an operation for biliary calculi; and McGuire 
removed one with monochlor acetic acid. Stelwagon 
commends trichloracetic acid, at first diluted, applied 
cautiously to a small part at a time, the reaction being 
controlled by vaselin or cold cream. Fuming nitric 
acid applied carefully by means of a small cotton swab 
in a series of dots will destroy them. Salicylic acid in 
collodion, 10 or 15 per cent., may be used. 

Pkognosis. — The growths when fully formed remain 
stationary, showing no tendency to change in any way, 
Exceptionally they may disappear of themselves. Treat- 
ment is most often disappointing, as when apparently 
removed they tend to return. 

Xanthoma Diabeticorum. — Besides the xanthoma just 
described, there is another form which is regarded as a 
distinct affection, and called Xanthoma diabeticorum. 

Symptoms. — It consists in the eruption of round, firm, 
dull red papules, on top of many of which is a yellow or 
yellowish-white head, and over many there are dilated 
vessels. Some papules may be pierced by hairs. They 
may be discrete or grouped or in lines. They may itch 
or pain, and are located especially on the buttocks, elbows, 
and knees, but may occur anywhere. The eruption 

1 Jour, de Med. et de Chir., April, 1866. 

2 Berlin, klin. Woehenschr., 1889, xxx, 393. 






736 . DISEASES OF THE SKIN 

appears suddenly, and after months or years may dis- 
appear quickly. Relapses may occur. 

Etiology.— As the name indicates, in most cases dia- 
betes is found, but it occurs without it at times. 

Pathology. — The disease process appears to be of the 
same nature as ordinary nodular xanthoma, but with 
more inflammatory phenomena and less connective-tissue 
growth (Crocker). 

Diagnosis. — It differs from ordinary xanthoma in its 
more sudden development; in disappearing sooner or 
later, perhaps to recur; in the hardness of its lesions, which 
are never macular; in the frequent absence of a yellow 
color; in the presence of a certain amount of inflamma- 
tion; in the absence of jaundice and presence of diabetes 
mellitus; in its more pruriginous character; in avoiding 
the eyelids; and in having its lesions about the mouths 
of the hair follicles. In fact, it resembles ordinary xan- 
thoma mostly in its location upon the elbows, knees, and 
other points of pressure, and in the general configuration 
of the lesions. 

Treatment should be directed to the diabetes, which 
is at the foundation of the disease, and to the allaying of 
the itching. 

Yaws. 1 — Synonyms: Framboesia tropica; Pian; Bouba; 
Parangi; Verruga; Granuloma seu Polypapilloma tropi- 
cum. 

This is a disease that occurs only in tropical countries. 
The stage of incubation lasts from two to eight weeks up 
to three or four months, and is without special symptoms. 
At the end of this stage the initial lesion appears. It is 
a pinhead-sized papule that becomes pustular, and then 
changes into an ulcer with perpendicular edges. The 
occurrence of the initial lesion is often unobserved, and 
some authorities deny its existence. The stage of inva- 
sion, with more or less well-marked fever and rheumatic 
pain, which abate before the eruption appears, lasts one 

1 This account is condensed from Crocker. 



YAWS 737 

or two weeks. The eruption is preceded by enlargement 
and tenderness of the lymphatic glands, and consists of 
pinhead- to lentil-sized, slightly elevated papules on a 
broad base. The papules enlarge; the epidermis splits 
and curls off from their centres, and exposes a yellowish 
point which develops into a flat, moist, red or pink tumor, 
looking not unlike a raspberry. These tumors range in 
size from that of a split pea to that of a nut, are round or 
oval, discrete or coalesced into large irregular masses. 
The surface of the tumor is covered with a thin, yellowish, 
foul-smelling discharge, that dries into a crust, which may 
ultimately assume a rupia form. In the mouth and in 
moist situations no crusts form, and the tumor will 
resemble a mucous patch. They reach their full develop- 
ment in from two to four weeks, remain stationary for 
months, and then dry up and fall off, leaving a stain on 
the skin, that eventually disappears. They may break 
down and ulcerate, involving both the adjacent soft 
parts and the bones. The tumors are not tender. The 
disease tends to recovery, but is subject to relapses. 
It is contagious, and one attack is protective to a certain 
extent. Death occurs in bad cases. It is supposed to be 
due to a specific micrococcus. Castellani 1 has found a 
special form of spirochete in the tumor which he named 
spirochete pertenuis, which is inoculable in monkeys. 
The Wassermann test is positive. It is probable that 
the disease is a form of syphilis. 

Diagnosis. — The diagnosis is from syphilis. It differs 
from it in attacking children specially, in having no 
initial lesion, in its lesions not showing polymorphism, in 
absence of lymphatic nodes, and in being itchy. More- 
over, the disease does not protect against syphilis. 

Treatment. — The treatment is the same as in syphilis 
— that is, by mercury and iodide of potassium, and care 
of the patient's general condition as to hygiene and sur- 
roundings. A number of cases have been cured by 

1 Jour. Cutan. Dis., 1908, xxvi, 151. 
47 






738 DISEASES OF THE SKIN 

injections of salvarsan. Locally, disinfectant and mer- 
curial applications should be used. 

Zoster. — Synonyms: Zona; Herpes zoster; Ignis sacer; 
(Ger.) Feuergiirtel, Gtirtelkrankheit; Shingles. 

An acute disease of the skin characterized by an uni- 
lateral eruption of groups of vesicles upon reddened bases 
scattered along the course of certain nerves. 

Symptoms. — Zoster, like psoriasis, presents such marked 
lesions that once seen it is readily recognized when 
seen again. It occurs in the form of groups of vesicles 
seated upon red bases, and arranged along the course 
of nerves upon which there are ganglia. The vesicles 
are at first filled with serum that afterwards may become 
cloudy. They do not tend to break down of themselves, 
but are frequently ruptured by accident. The size of 
the groups varies greatly. There may be but a few 
vesicles or a large number of them closely crowded 
together. Sometimes a group is no larger than a 
three-cent piece, and sometimes it is several inches in 
its longest diameter. Sometimes the vesicles may run 
together and form blebs. The shape of the groups is 
always irregular. There may be but two or three groups 
or a score of them. In nearly all cases the disease is 
unilateral, though it is not uncommon for one or two 
groups to be found close to the middle line, on the side 
opposite to the site of the disease. Cases of double 
zoster are very rare, usually with an interval of some days 
between the appearance of the lesions on the two sides, 
and practically never on the same plane. All the groups 
do not come out at once, but, as it were, by a series of 
outbreaks, the earliest ones to appear usually being 
those nearest the point of exit of the nerve. The eruption 
is usually at its height in a week, the vesicles drying up, 
forming a crust and falling off, leaving a red mark that 
soon fades. The whole duration of the disease is from 
ten days to three of four weeks. 

In many, if not most, cases the patient experiences 



ZOSTER 739 

neuralgic pain in the nerve along whose course the erup- 
tion is about to appear. This is sometimes wanting, and 
generally lessens or disappears when the eruption appears. 
Sometimes the pain is severe during the duration of the 
eruption, and after it is gone. Tender points may often 
be found over the points of exit of the nerves, like those 
found in neuralgia. In some patients there will be fever 
before the outbreak of the vesicles or the successive 
appearance of new groups. The vesicular stage is preceded 
by an erythematopapular stage. Very rarely some of the 
groups may abort at this stage. Exceptionally, zoster 
may occur on both sides of the body. In nearly all cases 
the disease does not recur. Exceptionally a patient may 
have several attacks of the disease. 

Most cases of zoster occur upon the trunk, and, it is 
said, especially on the right side. It also occurs upon 
the face, on branches of the fifth nerve, when it may 
involve the eye and produce blindness by destructive 
ulceration of the cornea. The neck may be affected, and 
with it the arm. The leg, too, may suffer. Generally the 
eruption does not reach further down than the elbow and 
knee, though it may occupy the forearm and hand, leg and 
foot. In rare instances the tongue and pharynx may be 
affected. Various names are used to designate the location 
of the eruption, such as zoster frontalis, ophthalmicus, 
cervicalis, intercostalis, genitocruralis, and the like. 

In rare cases hemorrhage may occur into the vesicles, 
or they may be purulent from the start, or they may 
ulcerate, or become gangrenous. The neuralgia may 
continue in old or debilitated subjects in so severe a 
manner as to threaten the exhaustion of the patient from 
pain and loss of sleep. Or pruritus, hyperesthesia, or 
anesthesia may be left for some time after the disappear- 
ance of the eruption. Or paralysis of motion may follow 
the attack, as well as atrophy of muscles. Scars will 
follow the disease if ulceration has occurred. 

Etiology. — Zoster occurs more often in children than 
in adults. Sex seems to have little influence. It follows 



740 



DISEASES OF THE SKIN 



upon^ injuries to nerves in some cases, and has been 
associated with caries of the ribs. It has been known to 
occur while the patient was taking arsenic. It occurs 
frequently in the damp, cold weather of the spring and 
autumn, so much so as to give rise to epidemics. Indeed, 
some regard the disease as infectious on account of the 
epidemic character it sometimes has. Some cases seem 
to arise from peripheral irritation of cutaneous nerves. 
A descending peripheral neuritis of the spinal ganglion is 
regarded by Crocker as the condition most frequently 
associated with the disease. He also regards the disease 
as of toxic origin. In a great number of cases disease of 

Fig. 115 




Zoster of arm. 



the ganglia upon the posterior roots of the spinal nerves 
has been found postmortem. When the fifth nerve is 
affected, it is the Gasserian ganglion that is diseased. 
Zoster may arise from injury, as a wound of a nerve- 
trunk, and then we may have an ascending zoster, the 
first group being nearest the point of injury. 

Pathology. — The zoster vesicle begins in the lower 
rete layer; the epithelial cells enlarge, assume vari- 
ous shapes, probably from pressure, and finally liquefy. 
Even in the formed vesicle some of the distended cells 
may be seen adherent to the floor. The roof is formed 
by the corneous layer. Besides serum and the debris 



ZOSTER 741 

of epithelial cells, the vesicles may contain few or many 
pus cells, and even in the hemorrhagic form, some red- 
blood corpuscles. There are secondary inflammatory 
changes in the rete and in the derma. 

J. F. Schamberg 1 says that on the posterior roots 
of the spinal nerves are found: (1) Acute inflammation 
with exudation of small, red, deeply staining cells. (2) 
Extravasation of blood. (3) Destruction of ganglion 
cells and fibres, and (4) Inflammation of the sheath of 
the ganglion. 

Diagnosis. — Zoster in most cases is readily recogniz- 
able. It differs from eczema in having larger vesicles 
that do not tend to rupture; in its patchy character, the 
patches being located along certain nerve-trunks; in the 
neuralgia that accompanies it, and in the definite course 
that it runs. Herpes facialis or progenitalis sometimes 
resembles zoster quite closely, but in them there will 
often be a history of previous attacks; they will not 
occur so markedly as groups of vesicles upon one side 
alone, and they will not be preceded by the same amount 
of neuralgia. By some authorities herpes and zoster are 
considered to be the same disease. 

Treatment. — The most important part of the treat- 
ment of zoster is to prevent the breaking of the vesicles 
and the possible ulceration that would follow and leave 
scars. To this end we should avoid ointments and use 
dusting powders, such as oxide of zinc, bismuth, starch, 
guaiacol, 5 per cent, with starch powder, or, what is 
better, we should paint the vesicles with flexible collodion 
with or without morphin, which sometimes seems to abort 
the formation of vesicles. The application of a 30 to 
50 per cent, aqueous solution of ichthyol is one of the 
best methods of treatment. It relieves the pain and 
protects the groups from rubbing by the clothing. It 
is also advisable to cover the eruption with a soft linen 
bandage to prevent rubbing. If the vesicles have become 

1 Jour. Amer. Med. Assoc, 1907, xlviii, 746. 



742 DISEASES OF THE SKIN 

broken and ulceration has ensued, then we have to treat 
the ulcers on surgical principles. 

To relieve the pain of zoster the galvanic current gives 
good results, one sponge electrode being placed over the 
spine, and a steel roller electrode attached to the other 
pole and passed around the groups for ten or fifteen 
minutes once or twice a day. A current-strength of 2 
or 3 ma. may be used, and, if it can be done, the last 
application should be made just before going to bed. 
Other means are hypodermics of morphin; blistering 
or dry cups over the root of the nerve; guaiacol as 
mentioned above, and the use of the menthol cone, or 
oil of peppermint. Phosphide of zinc, -J of a grain every 
three hours, is thought by some to relieve the pain and 
limit the eruption. For the persistent neuralgia that at 
times follows these cases, arsenic, or strychnin, iron, 
quinine, cod-liver oil, and a good, nutritious diet are 
necessary. Opium or other analgesic may have to be 
given to allay pain and procure sleep. 

Prognosis. — Most cases of zoster run a favorable 
course and get well of themselves. It is only in old or 
debilitated people that we need fear any serious results. 
There is always the possibility of the occurrence of ulcera- 
tion and gangrene, though it is not to be expected in the 
vast majority of cases. The popular opinion that if 
zoster occurs on both sides at once and forms a girdle the 
patient will die, has no foundation in fact, as such an 
occurrence is unknown. 



APPENDIX. 



The following formulae are given as guides in the preparation of 
prescriptions for the treatment of skin diseases. Many, if not all 
of them, have been well tried and their value proved. 

A. BATHS. 

Simple Water Baths: 

Cold 40°-65°F. 

Cool 65°- 75° F. 

Tepid 85°-95°F. 

Warm 95°-100° F. 

Hot 100°-110°F. 

Wet Pack. Wrap patient in a wet sheet and roll up in a blanket. 
After twenty to thirty minutes remove the pack, rub dry, and 
anoint with oil or ointment. Useful to remove the scales in psoriasis 
and to diminish hyperemia. 

Medicated Baths. To an ordinary bathtubful, say thirty 
gallons of water, add for 

Bran bath . . 2 to 6 pounds bran. 
Potato-starch bath 1 pound starch. 

Gelatin bath . . 1 to 3 pounds gelatin. 
Linseed " 1 pound linseed. 

Marshmallow bath 4 pounds marshmallow. 

Size bath . . . 2 to 4 pounds size. 

These baths are useful in erythematous, itchy, and scaly diseases. 
In using bran it should be tied up in cheese-cloth bags before 
being put in the water. 

For an alkaline bath add to bath, 

Bicarbonate of soda . . 2 to 10 ounces, or 

Carbonate of potassium . 2 to 6 " or 
Borax 3 " 

These baths are useful in eczema, psoriasis, urticaria, prurigo, and 
pruritic diseases. 

For an acid bath add to bath, 

Nitric acid 1 ounce, or 

Muriatic acid . , . . 1 " 
Or may use of each § " 

Of use in chronic pruritic disease. 



744 APPENDIX 

Iodine Bath: 

Iodine crystals \ to 1 drachm. 

Iodide of potassium, vel . . \ ounce. 

Liquor potassae 1 to 2 ounces. 

Glycerin 2 ounces. 

Add to 30 gallons of water. 

Useful in scrofulous and squamous diseases. 

Bromin Bath: 

Bromin 20 drops. 

Iodide of potassium . . . . . 2 ounces. 
Add to 30 gallons of water. 
Same indications as iodine bath. 

Sulphuret of potassium . . . 2 to 4 ounces. 
Add to 30 gallons of water. 
Used in scabies, chronic eczema, lichen, and psoriasis. 

Startin's Compound Sulphur Bath: 

Precipitated sulphur 2 ounces. 

Hyposulphite of soda 1 ounce. 

Water 1 pint. 

Add to 30 gallons of water. 

Same indications as the sulphuret of potassium bath. 

Mericurial Bath: 

Bichloride of mercury .... 3 drachms. 

Hydrochloric acid 1 drachm. 

Water 1 pint. 

Add to 30 gallons of water. 

Used in pityriasis rubra and the syphilides. 



B. FOR INTERNAL USE. 

1. Turpentine Emulsion: 

1^ — 01. terebinthinse, 1T|,x-xxx; 0.66-2 

01. limonis, mij; 12 

Mucilag. acacise, 5ss; 16 

Aquse destil., _ gss; 16 M. 

Sig. — A teaspoonful three times a day immediately after meals. 
One quart of barley-water to be drunk during twenty- 
four hours. (Crocker.) 
Used in psoriasis, eczema, and hyperemias. 

2. Mixed Treatment: 

a.T$ — Hydrarg. bichlor., . gr. j-iij; 06-.2 

Potass, iodid., 5iv-viij; 16-32 

Tinct. cinchon. co., giiiss; 112 

Aquse destil., ad giv; 120 M. 

Sig. — One drachm in water t. i. d. one hour after meals. 

(Taylor.) Used in syphilis. 



s 



APPENDIX 



745 



b. 1$ — Hydrarg. biniod., gr. ss-ij; 

Ammon. iodid., 5ss; 2 

Potass, iodid., 5ii~5j; 8-32 

Syr. aiirant. cort., §iss; 48 

Tinct. aiirant. cort., 5J5 4 

Aquae destil , ad § iij ', ad 100 
Sig. — One-half ounce t. i. d. after meals. (Keyes.) 

Used in 



1 03-. 13 



M. 



c. 1$ — Hydrarg. bichlor. vel, 

Hydrarg. biniod., gr. j-ij; 

Potass, iodid., 5j _ ijj 

Inf. gent. co. vel, 

Syr. sarsaparillse co., ad giv; 
Sig. — One drachm t. i. d. after meals. 
Used in syphilis. 



4-8 
ad 120 



06-.13 
M. 



3. I$— Pil. hydrarg., gr. xl; 2 66 

Ferri sulphat. exsic, gr. xx; 1 33 

Ext. opii, gr. v; 33 M. 

Div. in pil. No. xl. 
Sig— One t. i. d. (Taylor.) 
Used in syphilis. Sulphate of quinine may be substituted for 
the iron. 



4. 1$ — Hydrarg. chlor. mitis, gr. iss; 

Ferri lactatis, gr. iij ; 

Sacch. alb., gr. xv; 

Ft. in pulv. No. x. 

Sig. — One to four daily. (Monti.) 

Used in infantile syphilis. 



M. 



5. 1^—01. gurjun., §j; 

Liquor calcis, 5 iij; 

Sig. — One-half ounce twice a day. 
Used in leprosy. 



321 
100 



M. 



6. 1$ — Tine, cannabis indicae, Tltx-xxx; 0.66-2 

Pulv. tragacanth. co., gr. x; 

Aquae destil., ad Sj; ad 32 

Used in pruritus and prurigo. (Bulkley.) 



(50 



M. 



Startin's Mixture : 
1$ — Magnesii sulphat., 
Ferri sulphat., 
Acid, sulphur, dil., 
Syr. pruni Virgin., 
Aquae destil., 
Sig. — One drachm t. i. 
laxative and tonic. 



ad 



3vj-xij; 


24-48 




3j; 


4 




5ij; 


8 




5j; 


32 




5iv; 


ad 120 


M. 


*ter meals, 


through a tub 


e. As a 



746 APPENDIX 

8. Asiatic Pills: 

1$ — Acid, arsenosi, gr. xj; 75 

Pulv. pip. nigrae, 3iss; 6 

Gummi acaciae, gr. xxij; 1 05 

Pulv. althae rad., gr. xxx; 2 

Aquae destil., q. s.; q. s. M. 

Div. in pil. No. c. 

Sig. — One to three pills a day after meals, and increase to tol- 
erance. 
Used in psoriasis. 

C. FOR EXTERNAL USE. 

a. Caustics. 
1. Cosine's Paste: 

]$ — Acid, arsenosi, gr. x; 66 

Hydrarg. sulphuret. rub, 3ss; 2 

Ungt. rosae vel, 

Sacch. alb., gss; 16 

To destroy epithelioma or other new growths. 

2 Marsden's Paste: 

1$ — Pulv. acid, arsenosi, 5j~ij; 4-8 

Pulv. gummi acaciae, 

Orthoform, aa 3ss-j; 2-4 

Mix with a forty per cent, solution of cocaine to form a paste 
just before using, and apply to not more than one square 
inch at a time. 
Same indications as Cosme's Paste. 

3. Bougard's Paste: 
1^— Wheat flour, 

Starch, aa 60 parts. 

Arsenic, 1 part. 

Cinnabar, 

Sal ammoniac, aa 5 parts. 

Corrosive sublimate, \ part. 

Sol. chlor. of zinc @ 52°, 245 parts. M. 

Grind first six ingredients to a fine powder, then mix them in a 
mortar. Add solution of zinc chloride slowly stirring. Keep 
in earthen jar. May add cocaine up to 20 per cent, to allay 
pain. 
Sig. — Apply accurately to part; keep on for thirty hours; 
follow with poultice. 
Same indications as Cosme's Paste. 

4. Salicylic Acid (Crocker) : 

^— Glycerini, §j; 321 

Acid, salicyl., q. s.; q.s. | M. 

Make of consistency of thick cream. To lessen painfulness of 
application may add 
Ac. carbolici vel, 

Creosoti, 3j; 4| M. 
Used to destroy warts, lupus, and epidermic thickenings. 



APPENDIX 



747 



5. Vienna Paste: 

1$ — Calcis, 

Potassae, aa p. 

Make into a paste with alcohol just before using. 
Used in lupus and scrofulides. 



aa 4 1 



q. s. 



aa 16 1 

61 
321 



M, 



M. 



6. Canquoin's Paste: 
1$ — Zinci chlor., aa 5j; 

Ammon. chlor., 
Pulv. amyli, 5iss; 

Aquae destil., q. s.; 

Make into a paste at time of using. 
Used to destroy lupus, epithelioma, and the like. 

7. Middlesex Hospital Paste: 
1$ — Zinci chlor., 

Liq. opii sed., aa 5iv; 

Amyli, 5iss; 

Aquae destil., §j; 

Same indications as Canquoin's paste. 

8. Depilatory Paste: 

1$ — Barii sulphid., 5ij; 81 

Zinci oxidi, 

Amyli, aa* 5iij; 12 j M. 

Make into a paste with water and apply a thin coating for ten to 
fifteen minutes, then clean off and apply a bland ointment 



M. 



b. Lotions. 

1. Belladonna Lotion: 
ty — Tinct. belladon., 

Glycerini, aa 1 part. 

Aquae destil., 8 parts. 

For erysipelas. (Piffard.) 

2. Lotio Plumbi et Opii: 

1$ — Liq. plumbi subacetat. dil., aa 5j; 

Tinct. opii, ad Oj; 

For erysipelas and inflammatory conditions. 



3. Carbolic Acid Lotion: 




1$ — Acid, carbol., 


3j; 


Alcoholis, 




Aquae destil., aa 


Oss; 


For erysipelas. (White.) 




4. Bismuth Lotion: 




1$ — Bismuth, subnitrat., 


gr. viiss; 


Zinci oxidi. 


3ss; 


Glycerini, 


TUxv; 


Hydrarg. bichlor., 


gr. a; 


Aquae rosae, 


5j; 



M. 



aa 321 
ad 500 M. 



aa 2401 M. 



For rosacea and hyper emic conditions. 



016 
M. 



18 


APPENDIX 






5. Lotto Alba: 

1$ — Potassae sulphurat 

Zinci sulphat., 

Aquae rosae, 
For acne and rosacea. 


> 

aa 
ad 


5j; 

Siv; 


aa 
ad 


4 
128 


6. Kummerf eld's Lotion: 
fy — Spts. camphorae, 
Spts. lavandulae., 


aa 


3ss; 


aa 


2 


Sulph. precip., 
Aq. cologniensis, 
Aqu83 destil., 
For acne. 




gr. xv. 

5j; 

Sij; 




1 

4 
64 


7. Sulphur Lotion: 
1$, — Sulphuris loti, 
Alcoholis, 
Etheris, 
Glycerini, 
Potass, carb., 
Aq. rosae, 

Used in acne. 


aa 


Sij; 

Bvij; 


aa 
ad 


8 
250 



M. 



M. 



M. 



8. Vleminckx's Solution: 

1$ — Calcis vivae, 3iv; 16 

Sulphur, sublimat., §j; 32 

Aq. destil., gx; 320 M. 

Boil together with constant stirring until the mixture measures 
six fluid ounces (190), then filter. 
Useful in scabies, psoriasis, and acne. 



9. Calamin Liniment: 

1$ — Pulv. calamin., gr. xl; 2 

Zinci oxidi, 3ss; 2 

Linimenti calcis, 5 j ; 32 

For erythema, eczema, and hyper emic conditions. 



6G 



M. 



10. Calamin Lotion: 




1$ — Pulv. calamin., 


gr. xx ; 


Zinci oxidi, 


5i; 


Glycerini, 


5j; 


Aq. calcis, 


3yj; 


Aq. rosae, 


ad §iv; 


For erythema and eczema. 





1 

4 

4 

24 

128 



32 



M. 



11. Liquor Picis Alkalinus: . 

1$ — Picis liquidae, § ij ; 64 

Potass, causticae, 5j; 32 

Aquae destil., 3v; 20 M. 

Dissolve the potassa in the water and add slowly the tar in a 
mortar with friction. 
For chronic eczema, or, diluted ten to twenty times, for acute 
eczema. 



APPENDIX 




2. Piffard's Substitute for 


Tar 






1$ — Ac. salicyl., 




gr. x-xxx; 


0.66-2 


01. lavandulse, 




3iiss; 


10 


01. citronellse, 




3ss; 


2 


01. pini sylvestris, 




5ij; 


60 


01. ricini, 




§iss; 


45 


For eczema capitis. 









749 



13. Tinct. Saponis Co. of Hebra: 
Of, — 01. cadini, 

Sapo. viridis, 

Alcoholis, aa § j ', 

Filtra et adde 

Spts. lavandulse, 5ij; 

Stimulant in chronic eczema. 

14. Carron Oil: 

1$ — Aq. calcis, 
01. olivse vel, 
01. lini, 
For burns. 

15. Fox's C. C. C. Mixture: 
1$ — Chrysarobin., 

01. cadini, 
Acid, carbolici, 
Acid, oleici, 
For psoriasis. 

16. Kaposi's Tar Lotion: 
1^—01. rusci, 

Etheris sulphuris, 
Alcoholis, 
Filtra et adde 

01. lavandulse, 
Used in psoriasis. 

17. 1$ — Amyli glycerolis, 

01. cadini, 
Sapo viridis, 
For psoriasis. External use. 

18. Hardaivay's Lotion for Licftcn Planus: 



aa 32 



2 
1 

50 


parts 
part, 
parts 


50 


parts 


75 


a 


2 


a 


5 


parts 



-Sapo. olivse prep., 


oiv; 


01. rusci, 




Glycerini, 


aa Sj; 


01. rosmarini, 


5iss; 


Alcoholis, 


ad § viij ; 



ad 



128 

32 

6 
250 



M. 



M, 



Equal parts. M, 



M. 



M. 



M. 



M. 



19. Lotio Ac. Boracis: 

3^— Ac. boracis, 5iv vel q. s.; 1601 

Etheris sulph. methyl., §v; 160 1 

Spts. vini rect., ad gxx; ad 640 1 M. 

For ringworm, after washing with hot water and soap, and drying. 
(A. Smith.) 



30 


APPENDIX 


0. I$— Naphtoli, 

Spts. sapo. viridis 
Alcoholis, 


gr. xv ; 
5vj; 

giss; 


Bals. peruv., 
Sulph. loti, 
For sycosis. (Kaposi.) 


gtt. XXX 

Siiss; 



M. 



21.1$ — Sodii hypophosphitis, Sj; 
Glycerini, gss; 

Aquae destil . , 5 vii j ; 

For dermatitis venenata. (Morrow.) 



32 

16 

256 



M. 



22. I$— Zinci oxidi, 

Magnesii carbonat., aa 5j; 
Aristol, 5 ij 5 
Aquae rosae, ad §iv; 
Sig. — For dermatitis venenata. 


23. 1^— Zinci oxidi, 
Ac. carbol., 
Aquae calcis, 
For dermatitis venenata. 


3iv; 
5j; 
ad Oj; 

(White.) 


24. Thymol Lotion: 
fy— Thymol., 

Liq. potassae, aa 5j; 
Glycerini, 5 ss ; 
Aq. sambuci, gviij; 
For pityriasis capitis. Also for prurit 
amount of thymol. 


25. 1$ — Pilocarpin. muriat, 
Aquae rosae, 
Alcohol @ 75°, 


gr. vij 

5ij; 

5vj; 



ad 



4 

8 

120 



161 

4| 
ad 500| M. 



Sig. 
26. I$- 



Etheris, 

Spt. lavandulae, aa 5vj 

— Hair lotion (Sabourand.) 



4 

16 

256 



60 
180 

24 



M. 



-Hydrarg. bichlor., 
Resorein vel, 



gr. iv ; 



Euresol pro capillis, 3 ij ', 




8 


Spts. formicari, 5j; 




32 


01. ricini, 3j~hj 




4-12 


Alcohol© 70°, ad gviij; 




250 


Sig.— Hair lotion. (White.) 






c. Ointments. 






1. Bassorin Paste: 






1$ — Bassorin, 




48 parts. 


Dextrin, 




25 " 


Glycerin, 




10 " 


Water, 


ad 


100 " 



24 



M. 



APPENDIX 




751 


2. Gelatin Paste (Unna) : 








1$ — Zinci oxidi, 




30 parts. 




Gelatini, 




30 " 




Glycerini, 




39 " 




Aquae destil., 




10 " 


M. 


Heat in water bath before 


using. 






As a protective dressing and excipient. 






3. 1$ — Hydrarg. protiodod., 


gr. v-xv; 


0.33-1 




Hydrarg. ammon., 


gr. x-xxx; 


0.66-2 




Ungt. simplicis, 


5j; 


32 


M. 


Used in acne. (Duhring.) 








4. 1^ — Ungt. lanae, 


3 iiss ; 


10 




Ac. acetici, 


3ij gr. xlv; 


11 




Adepis benzoat., 


5 iiss ; 


10 




Sulph. precip., 


gr. xlv; 


3 


M. 


Used in acne. (Unna.) 








5. Naphtol Ointment: 








1$ — /3-naphtol., 




10 parts. 




Sulph. precip., 




50 " 




Vaselini, 








Sapo. viridis, 


aa 


25 " 


M. 


Used in acne. (Lassar.) 








6. Lassar' s Paste: 








1$ — Zinci oxidi, 








Amyli, aa 


5ij; 


aa 8 




Vaselini, 


5iv; 


ad 32 


M. 


Used in eczema. 








7. 1$ — Zinci oxidi, 




40 parts. 




Creta preparat., 








Liquor plumbi, 


aa 


20 " 




01. lini, 








Mix the first two together, 


and the last two together, 


and add 


one part to the other. 








Use as a protective in eczema 


. (Unna.) 






8. fy—0\. cadini, 








Zinci oxidi, aa 


5ss-j; 


aa 2-4 




Ungt. aquae rosae, 


Sj; 


32 


M. 


For chronic eczema. 








9. Sulphur Cream: 








fy — Cerae albae, 


5iijss 


14 




01. petrolati, 


5 iiss; 


80 




Aquae rosae, 


Sj-5ij; 


40 




Sodae biborat., 


gr. xvnj; 


1 


18 


Sulphur precipitat., 


5 hiss; 


14 





Used in seborrheal dermatitis and pityriasis capitis. 



752 



APPENDIX 



10. 1$ — Hydrarg. ammon., gr. xx-xl; 5-10 

Hydrarg. chlor. mitis, gr. xl-lxxx; 10-20 

Vaselini, ad %'y, 'ad 100 
Used in 'pityriasis capitis. (Bronson.) 



M. 






11. Bismuth Ointment: 




1$ — Bismuthi subnit., 




Kaolini, aa, 


5iss; 


Vaselini, ad 


giss; 


For chloasma. (Unna.) 




12. Chrysarobin Ointment: 




T$ — Chrysarobin, 


gr. 1; 


Ac. salicylici, 


gr. x; 


Plasment. vel 




Adipis, ad 


Si; 


Used in psoriasis and ringworm. 


13. 1$ — Chrysarobin, 




Ichthyol., aa 


gr. Ixxv; 


Ac. salicyl., 


gr. xxx ; 


Ungt. simpl., ad 


Biij; 


Used in leprosy. (Unna.) 





14. 1$ — Hydrarg. amnion., 

Bismuthi subnit., aa 5jj' 
Ungt. aq. rosae, ad §j; 
Used in lentigo. (Hardaway.) 

15. 1$ — Ac. salicylici, gr. x; 

Ungt. hydrarg. ox. rub., §j; 
Ungt. aquae rosae, 3vj; 

For blepharitis. (Webster.) 

16. 1$ — Hydrarg. sulph. rubri, gr. xv: 

Sulph. sublimat., 5vj; 

Adipis, ad § iij ; 

01. bergamot., q. s.; 
Used in sycosis. (Behrend.) 

17. B,— Ungt. diachyli (Hebra), 

Ungt. zinci oxidi, aa Siss; 
Ungt. hydrarg. ammon., 5 iij 5 
Bismuthi subnitrat., 5iss; 
For sycosis. (Robinson.) 

18. B,— 01. fagi, 

Flor. sulph., aa 5iiss; 

Pulv. cretae alb., 5 '■, 

Adipis, 

Sapo. viridis, aa 5v; 

For sycosis. (H. Hebra.) 



aa 6 
ad 48 



3 
ad 32 



aa 


5 




2 


ad 


126 



aa 4 
ad 32 



1 

24 
ad 100 

q. s. 



aa 48 

12 

6 



M. 



M. 



M. 



M. 



66 



M. 



M. 



M. 



aa 


10 




4 


aa 


20 



M. 





APPENDIX 




19. Naphtol Ointment: 








J$ — /3-naphtol, 




3uj gr. xl; 


15 


Creta preparat., 




3hss; 


10 


Sapo. viridis, 




5iss. 


50 


Adipis, 


ad 


5iij; 


ad 100 


Used in scabies. (Kaposi.) 






20. I$— Sulphur., 




Si; 


32 


Potass, carb., 




3ij; 


8 


Adip. benzoat., 




5v; 


160 


01. chamomilis, 




5ss; 


2 


Used in scabies. (Wilson.) 






21. Helmerich's Ointment: 








fy — Sulphur., 




5ij; 


32 


Potass, carb., 




Si; 


16 


Adipis, 




Svuj; 


256 


Used in scabies. 








22. Wilkinson' s Ointment 


(Hebra): 




1$ — Sulphuris, 








01. cadini, 


aa 


gss; 


aa 16 


Sapo. viridis, 








Adipis, 


aa 


5i; 


aa 32 


Creta preparat., 




3iiss; 


10 


Used in scabies. 








23. 1$ — Ac. salicylici, 






2-3 parts. 


Sulphur, precip., 






10-15 " 


Lanolini, 






70 " 


Vaselini, 






18 " 


For chromophytosis. (Brocq.) 






24. 1$ — Hydrarg. bichlor. 




gr. j-v; 


0.6-0.3 


Ac. carbol., 




gr. xx ; 


1.3 


Ungt. zinci oxidi, 


ad 


Si; 


ad 32 


Used in lichen ruber. (Unna. 


) 




25. 1$ — Ac. salicylic, 




gr. x; 




Colloidal sulphur, 




3j; 


4 


Eucerin, 




5vj; 


24 


Adipis anserini, 




3j; 


4 


01. rosse geran, 




gtt. xv ; 


1 


Used in sycosis. 








d 


Miscellaneous. 




1. Anti-pruritic Powder: 








fy — Camphori, 




3ss; 


2 


Zinci oxidi, 




3ij; 


8 


Amyli, 




3iv; 


16 



53 



M. 



M. 



M. 



M. 



M. 



66 



M. 



M. 

(Bulkley.) 



48 



754 



APPENDIX 






2. Corn Remedy: 
1% — Ac. salicylici, 

Ex. cannabis indicse, 
Alcoholis, 
Etheris, 
Collodion flex., 



gr. xv ; 1 
gr. viij; 

mxv; 1 

lUxl; 2 

mlxxv; M. 
Apply with brush three times a day for a week. Soak feet and 
pick out corn. (Vigier.) 



Emulating stick: 

I$— Cera flavse, 5iij; 12 

Laccse in tabulis, 5iv; 16 

Picis Burgundicse, 5x; 40 

Gummi damar, 5iss; 48 

Make in sticks one-half to one inch in diameter and two inches 
long. (Bulkley.) 



4. Glycerin Jelly: 
1$ — Gelatini, 


gr. xxv ; 


Glycerin, 
Aquse destil., 


gr. ccxxv; 
3iv; 






5. Glycerole of Subacetale of Lead: 

I$— Plumbi acetat., gr. cxx; 8 

Plumbi oxidi, gr. lxxxiv; 6 

Glycerini, 5j; 32 M. 

Digest the lead in the glycerin heated to 300° F. in an oil bath 

for half an hour, constantly stirring. Filter in a chamber 
heated to 300° F. 






INDEX. 



Abscess, 59 ' 

Acanthosis nigricans, 60 
Acantholysis, 60 

bullosa, 271 
Acarodermatitis urticariodes, 61 
Acarus scabiei, 593 
Achorion Schoenleinii, 317 
Achroma, 729 
Acne, diagnosis, 69 
etiology, 65 
pathology, 68 
prognosis, 79 
symptoms, 62 
treatment, 71 

agminata, 81 

albida, 460 

artificialis, 79 

atrophica, 80 

bromic, 193 

cachecticorum, 80 

decalvant, 330 

erythematosa, 574 

follicularis, 154 

frontalis, 81 

indurata, 64 

iodic, 194 

keloid, 197 

keratosa, 80 

lupoid, 81 

mentagra, 620 

necrotica, 81, 84 

necroticans et exulcerans 
nasi, 83 

papulosa, 62 

pilaris, 81, 330 

punctata, 63, 154 

pustulosa, 63 

rodens, 81 



Acne rosacea, 574 

scrofulosorum, 83 

sebacea, 609 

simplex, 62 

sycosis, 620 

tar, 79 

telangiectodes, 81 

urticata, 83 

varioliformis, 81, 328, 461 

vulgaris, 62 
Acne arthritique, 81 

fluente, 609 

keloidique, 197 

miliare scrofuleuse, 81 

punctuee, 154 

sebacee cornee, 395 

ulcereuse, 81 
Acnitis, 81 
Acrochordon, 326 
Acrodermatitis chronica atrophi- 
cans, 84, 123 

perstans, 84 
Acrodynia, 85 
Acromegalia, 267 
Acromegaly, 85 
Actinomycosis, 85 
Actinotherapy, 41 
Adenocarcinoma, 86 
Adenoma sebaceum, 87 

sudoriferum, 87 
Adenotrichie, 620 
Ainhum, 87 
Albinism, 88 
Aleppo boil, 88 

bouton, 88 
m evil, 88 
Algidite progressive, 599 
Alopecia adnata, 89 

areata, diagnosis, 106 
etiology, 103 



756 



INDEX 



Alopecia areata, pathology, 105 
prognosis, 109 
symptoms, 100 
treatment, 106 

atrophica, 329 

cicatrisata, 330 

circumscripta, 100, 329 

follicularis, 100 

orbicularis, 329 

pityrodes, 95 

prematura idiopathica, 91 
symptomatica, 94 

seborrhoica, 95 

senilis, 90 

syphilitica, 98 
Alopecies cicatricielles innomi- 

nees, 330 
Alphos, 545 
Analgesia, 110 
Anesthesia, 110 
Angiokeratoma, 110 
Angioma, 477 

infective, 112 

pigmentosum et atrophicum, 
120 

serpiginosum, 112 
Angiomyoma, 472 
Anhidrosis, 114 
Anidrosis, 114 
Anonychia, 114 
Anthrax, 134, 570 
Aplasia pilorum intermittens, 119 
Area celsi, 100 

occidentalis diffluens, 100 

serpens, 100 

tyria, 100 
Argyria, 114 
Arrectores pilorum, 27 
Asiatic pill, 745 
Asteatosis, 114 
Atheroma, 160 
Atrophia cutis, 120 

maculosa cutis, 123 

pilorum propria, 115 

unguium, 119 
Atrophoderma, 120 

albidum, 123 

idiopathica diffusa, 123 

pigmentosum, 120 

senilis, 124 

striatum et maculatum, 125 
Aussatz, der, 407 



B 



Bacillus acnes, 66 

leprae, 413 

mallei, 285 

prodigiosus, 145 
Bacteriotherapy, 50 
Bacterium prodigiosus, 407 
Bad disorder, 631 
Baelz's disease, 126 
Baldness, 89 

circumscribed, 100 

congenital, 89 

premature, 91 

senile, 90 
Barbadoes leg, 264 
Barber's itch, 620, 691 
Bartfinne, 620 

parasitische, 691 
Bartflechte, 620 
Baths, 743 
Bed-bug bites, 493 
Beigel's disease, 126 
Birthmark, 477 
Blackheads, 154 
Blasenausschlag, 505 
Blastomycetic dermatitis, 163 
Bleb, 33 
Bloodvessels, 21 
Blutfleckenkrankheit, 564 
Blutschwar, 337 
Boil, 337 

Botryomycosis hominis, 127 
Bouba, 736 

Bougard's paste, 282, 746 
Bouton, 62 
Brandschwar, 134 
Bromidrosis, 128 
Bronson's ointment, 205 
Bucnemia tropica, 264 
Bulla, 33 
Bulpiss, 129 
Bunion, 130 
Burning, 39 



Cacotrophia folliculorum, 399 
Calamin lotion, 748 
Calculi, cutaneous, 460 
Callositas, 130 



INDEX 



757 



Callosity. 130 

Callus, 130 

Calvities, 89 

Cancer, chimney-sweep's, 276 

en-cuirasse, 138 

epithelial, 272 

skin, 272 

spider, 681 

tubereux, 390 
Cancroid, 272 
Canities, 131 
Canquoin's paste, 746 
Caraate, 517 
Carbon dioxide, 48 
Carbuncle, 134 
Carcinoma, 137 

lenticulare, 138 

melanodes, 138 

tuberosum, 138 
Carron oil, 749 
Cataphoresis, 50 
Causalgia, 162 
Chalazion, 460 
Chalazodermia, 213 
Chaleur du foie, 140 
Chancre, 631 
Chap, 139 
Charbon, 570 
Cheilitis exfoliativa, 139 

glandularis aposthematosa, 
139 
Cheiro-pompholyx, 529 
Cheloide, 390^ 
Chicken-pox, 723 
Chigoe, 493 
Chilblain, 168 

necrotising, 328 
Chloasma, diagnosis, 142, 146 

etiology, 142 

prognosis, 143 

symptoms, 140 

treatment, 142 

uterinum, 141 
Chorionitis, 601 
Chromidrosis, 143 
Chromophytosis, 146 
Cicatrix, 36 
Cimex lectularius, 493 
Claret stain, 477 
Classification, 52 
Clastothrix, 116 
Clavus, 151 



Clavus syphiliticus, 153 
Clou, 337 
Cnidosis, 715 
Cochin-China leg, 264 
Cold sore, 350 
Colloid degeneration, 153 

milium, 153 
Columnae adiposae, 21 
Comedo, 154 
Condyloma acuminata, 726 

lata, 641 
Congelation, 48 
Connective tissue, subcutaneous, 

21 
Cor, 151 
Corium, 20 
Corn, 151 

Corne de la peau, 158 
Cornu cutaneum, 158 

humanum, 158 
Corpuscles of Krause, 23 

of Meissner, 22 

Pacinian, 23 

tactile, 22 
Cosme's paste, 746 
Couperose, 574 
Crab louse, 497 
Craw-craw, 159 
J Crust, 34 
Crusta lactea, 245 
Cute, 517 
Cuticle, 17 
Cutis anserina, 159 

laxa, 213 

pendula, 213 

verticis gyrata, 159 
Cyanopathie cutanee, 144 
Cyst, dermoid, 159 

sebaceus, 160 
Cystecercus cellulosse cutis, 161 



Dactylitis, 664 
Dandruff, 518 
Darier's disease, 394 
Dartre erythemoide, 293 

humide, 218 

pustuleuse mentagre, 620 

rongeante, 444 

vive, 218 



758 



INDEX 



Dasyma, 364 
Defluvium capillorum, 99 
Demodex folliculorum, 156 
Depilatory paste, 747 
Dermatalgia, 161 
Dermatitis ambustionis, 166 
blastomycotica, 163 
bullosa, 271 
calorica, 166 
coccidioides, 347 
congelationis, 168 
contusiforme, 304 
eczematoid, 263 
epidemica, 174 
erythematosa, 293 
exfoliativa, diagnosis, 172 

etiology, 171 

neonatorum, 175 

pathology, 172 

prognosis, 174 

symptoms, 170, 171 

treatment, 173 
factitia, 176 
fungoid, 467 
gangrenosa, 178 

infantum, 179 
glandularis erythematosa, 

435 
herpetiformis, diagnosis, 185 

etiology, 184 

pathology, 185 

prognosis, 187 

symptoms, 181 

treatment, 187 
malignant papillary, 486 
medicamentosa, 188 
multiforme, 180 
papillaris capillitii, 197 
papillomatosa capillitii, 197 
psoriasiformis, 491 

nodularis, 491 
repens, 198 
seborrhoica, diagnosis, 203 

etiology, 202 

pathology, 203 

prognosis, 206 

symptoms, 200 

treatment, 204 
traumatica, 206 
uncinarial, 348, 714 
variegata, 491 
vegetans, 207 



Dermatitis venenata, diagnosis, 

210 

pathology, 210 

symptoms, 208 

treatment, 210 

verrucosa, 213 

z-ray, 199 
Dermatobia noxialis, 493 
Dermatolysis, 213 
Dermatomycosis favosa, 313 

furfuracea, 146 

microsporina, 146 

tonsurans, 687 
Dermatosclerosis, 601 
Dermatosis Kaposi, 120 
Desmoides, 326 
Dhobie itch, 214 
Diabetic eruptions, 214 
Diagnosis, general, 29 

color in, 38 

configuration in, 38 

history in, 39 

location in, 36 

microscope in, 40 
Diaskop, 41 
Diphtheria of skin, 215 
Distichiasis, 215 
Dracontiasis, 349 
Dracunculus, 349 
Duhring's disease, 181 
Durillon, 130 
Dysidrosis, 529 



ECDERMOPTOSIS, 461 

Ecphyma globulus, 216 
Ethyl chloride, 48 
Ecthyma, 216 

infantile gangreneux, 179 
terebrant de l'enfance, 179 
Eczema, diagnosis, 227 
etiology, 224 
pathology, 226 
prognosis, 242 
symptoms, 219 
treatment, 231 
ani, 242 
aurium, 244 
barbae, 245 
capitis, 245 



INDEX 



759 



Eczema crurum, 248 

exfoliativum, 169 

foliaceum, 169 

genitalium, 248 

hypertrophicum, 467 

infantile, 257 

intertrigo, 250 

labiorum, 250 

madidans, 222 

mammarum, 250 

mammillarum, 250 

manuum, 252 

marginatum, 261, 686 

narium, 254 

orbicular, 224 

palpebrarum, 255 

pedum, 256 

rimosum, 220 

rubrum, 222 

seborrhoicum, 200, 519 

tuberosum, 467 

unguium, 256 

universale, 251 

varicosum, 224, 248 

verrucosum, 224 
Eczematoid dermatitis, 263 
Eiterpusteln, 216 
Elastic skin, 213 
Elephantiasis, diagnosis, 268 
etiology, 267 
pathology, 268 
prognosis, 269 
symptoms, 264 
treatment, 268 

Arabum, 264 

Grecorum, 407 

Indica, 264 
Emphysema of skin, 269 
Endothelioma, 270 
Endurcisement athrepsique, 599 
Ephelides, 404 
Ephidrosis, 360 

cruenta, 350 

tincta, 143 
Epidermis, 17 
Epidermodophyton, 553 

inguinale, 261 
Epidermolysis bullosa, 271 
Epithelialkrebs, 272 
Epithelioma, diagnosis, 279 
etiology, 276 
pathology, 277 



Epithelioma, prognosis, 284 

symptoms, 273 

treatment, 280 
adenoides cysticum, 284 
contagiosum, 461 
multiple benign cystic, 284 
Epitheliomatose eczematoide de 
la mamella, 486 
pigmentaire, 120 
Equinia, 285 
Erbgrind, 313 
Eruption, creeping, 374 
feigned, 176 
recurrent summer, 358 
ringed, 345 
Erysipelas, diagnosis, 289 

etiology, 288 

prognosis, 292 

symptoms, 286 

treatment, 290 
chronic, 292 
suffusum, 293 
Erysipeloid, 292 
Erythema, 285 
annulare, 301 
bullosum, 302 
caloricum, 294 
circinatum, 301 
elevatum diutinum, 308 
epidemicum, 85 
exudativum, 300 
figuratum perstans, 308 
fugax, 296 
gyratum, 302 
hyperemicum, 293 
induratum scrofulosorum, 

309 
intertrigo, 294 
iris, 303 
laeve, 296 
marginatum, 301 
migrans, 292 
multiforme, diagnosis, 306 

etiology, 305 

pathology, 306 

prognosis, 308 

symptoms, 300 

treatment, 307 
neonatorum, 298 
nodosum, 304 
paratrimma, 296 
pernio, 168, 294 



760 



INDEX 



Erythema perstans, 302 

roseola, 297 

scarlatiniforme, 298 

simplex, 294 

tuberculatum, 301 

traumaticum, 294 

urticans, 297 
Erytheme centrifuge, 435 

noueux, 304 

papuleux desquamatif, 521 
Erythrasma, 310 
Erythrodermia, congenital ich- 

thyosiforme, 311 
Erythrodermie exfoliante, 169 

pityriasique en plaques, 492 
Erythromelalgia, 312 
Esthiomene, 312, 444, 
Examination of patient, 40 
Exanthem, psoriasiform and 

lichenoid, 492 
Excoriation, 35 



Farcy, 285 

Favus, diagnosis, 320 

etiology, 317 

pathology, 317 

prognosis, 324 

symptoms, 314 % 

treatment, 321 
Feigned eruptions, 176 
Feu sacre, 286 
Feuergiirtel, 738 
Feuermal, 472 
Fever-blister, 350 
Fibroid, recurrent, 586 
Fibroma, 325 

fungoides, 467 

lipomatodes, 732 

molluscum, 325 

pendulum, 325 
Fibromvoma, 472 
Fikosis,~ 620 
Finnen, 62 
Finsen light; 42 
Fischschuppenausschlag, 375 
Fish-skin disease, 375 
Fissure, 35 
Flea bites, 327, 493 
Flechte, fressende, 444 



Flechte, kleien, 146 

nassende, 218 

scheerende, 685, 687 
Fleckenmal, 473 
Fleshworms, 154 
Fluxus sebaceus, 609 
Folliclis, 328, 608 
Folliculitis, 329 

desseminees des parties glab- 
res, 328 
Folliculitis barbae, 620 

decalvans, 329 

depilating, 333 
of limbs, 335 

pilorum, 620 
Foot, tubercular disease of, 

336 
Fordyce's disease of lips, 335 
Fragilitas crinium, 115 
Frambcesia, 197, 736 
Freckles, 404 
Friesselauschlag, 457 
Frost-bite, 168 
Fungous foot of India, 336 
Furuncle, 337 
Furunculi atonici, 216 
Furunculus, 337 



Gale, 590 
Gangosa, 343 

Gangrene, multiple cachectic, 
179 

symmetrical, 178 
Gefassmal, 477 
Gelatin paste, 750 
Gerromorphism cutanee, 344 
Glandular disease of Barbadoes, 

264 
Glands, sebaceous, 25 

sweat, 26 
Glanders, 285 
Glossy skin, 123 
Gnat bites, 493 
Gneis, 609 
Goose-flesh, 159 
Grain itch, 61 
Granuloma annulare, 345 

coccidioidal, 347 

fungoides, 467 



INDEX 



'61 



Granuloma innominee, 328 
necrotica, 328 
pyogenicum, 347 
tricfiophyticum, 689 
tropicum, 736 

Granulosis rubra nasi, 348 

Gra}mess, 131 

Ground itch, 348 

Grubs, 154 

Grutum, 460 

Guinea-worm disease, 349 

Gum, red, 571 

Gumma, scrofulous, 607 
syphilitic, 652 

Giirtelkrankheit, 738 

Gutta rosacea, 574 
rosea, 574 



Hair, anatomy of, 23 

beaded, 119 

blanching of, 131 

discolorations of, 350 

nodose, 119 

ringed, 132 

superfluous, 364 
Hand-and-foot disease, 513 
Harlequin fetus, 378 
Harvest bug, 493 
Hauthorn, 158 
Hautnervenschmerz, 161 
Hautrose, 286 
Hautrothe, 293 
Hautschmerz, 161 
Hautsclereme, 601 
Hautwiirmer, 154 
Heat eruption, 218 
Helmerich's ointment, 752 
Hematidrosis, 349 
Hemiatrophia facialis progres- 
siva, 124 
Hemidrosis, 349 
Hemorrhea petechialis, 564 
Hemisporosis, 350 
Henoch's purpura, 567 
Hernia carnosa, 264 
Herpes circinatus, 180, 303, 685, 
687 

esthiomenes, 444 

facialis, 350 



Herpes febrilis, 350 

gestationis, 180, 356 

iris, 303 

labialis, 350 

phlyctenodes, 180 

preputialis, 353 

progenitalis, 353 

pustulosus mentagra, 620 

squamosus, 687 

tonsurans, 687 
barbae, 691 
maculosus, 521 

zoster, 738 
Herpetide, 356 

exfoliative, 169 
Hide-bound disease, 601 
Hidrocystoma, 356 
High-frequency current, 47 
Hirsuties, 364 
Hitzblatterchen, 218 
Hives, 715 
Homines pilosi, 364 
Horn, cutaneous, 158 
Hiihnerauge, 151 
Hutchinson's teeth, 663 
Hyalom der Haut, 153 
Hydradenitis destruens suppura- 
tiva, 81 
Hydradenomas eruptifs, 284 
Hydroa, 180, 303 

bulleux, 183 

estivale, 358 

febrilis, 350 

herpetiforme, 182 

puerorum, 358 

vacciniforme, 358 

vesiculeux, 303 
Hydrosadenite disseminee sup- 
purativa, 328 
Hyperalgesia, 360 
Hyperesthesia, 360 
Hyperidrosis, 360 

oleosa, 613 
Hyperkeratosis atrophica, 
531 

excentrica, 531 

follicularis, 399 

linguae, 127 
Hypertrichosis, etiology, 367 

symptoms, 364 

treatment, 370 
Hyponomoderma, 374 



762 



INDEX 



Ichthyose anserine des scrofu- 

leux, 399 
Ichthyosis, diagnosis, 379 
etiology, 378 
pathology, 379 
prognosis, 381 
symptoms, 375 
treatment, 379 
congenita, 375 
follicularis, 394, 399 
hystrix, 377, 490 
intra-uterina, 378 
linguae, 418 

palmaris et plantaris, 398 
sebacea, 609 

cornea, 394 
vera, 375 
Idrosis, 360 
Ignus sacer, 738 
Impetigo, Bockhardt's, 382 
contagiosa, diagnosis, 386 
etiology, 385 
pathology, 386 
prognosis, 389 
symptoms, 382 
treatment, 389 
herpetiformis, 389 
parasitica, 382 
simplex, 381 
streptogenes, 382 
Induratio telae cellulosae, 

599 
Initial lesion, 631 
Intertrigo, 294 
Iodic acne, 194 
Itch, 590 

barber's, 620, 691 
bricklayer's, 252 
Dhobie, 214 
grain, 61 
grocer's, 252 
prairie, 534 
washerwoman's, 252 
Lxodes, 493 . 



Jigger, 493 
Juckblattern, 534 



Kahlheit, 89 

kreisfleckige, 100 
Kelis, 390 
Keloid, 390 

Addison's, 603 

Alibert's, 394 
Keratodermia gonorrhoica, 394 

eccentrica, 531 
Keratolysis exfoliativa, 394 

neonatorum, 175 
Keratoma, 130 

follicularis, 378 

palmare et plantare, 398 
Kerratosis diffusa, 378 

epidermica, 378 

follicularis, 394 

contagiosa, 397 

intra-uterina, 378 

palmaris et plantaris, 398 

pilaris, 399 

senilis, 401 
Kerion, 402 

Celsi, 402 
Knollenkrebs, 390 
Koilonychia, 403 
Koltun, 527 
Kratze, 590 
Kraurosis vulvae, 404 
Kummerfeld's lotion, 747 
Kupferflnne, 574 
Kupferrose, 574 
Kupfrige gesicht, 574 



Lamp, iron electrode, 42 

Kromayer, 43 

mercury, 42 

uviol, 43 
Larva migrans, 374 
Lassar's paste, 751 
Leberflecken, 140 
Leichdorn, 151 
Leiomyoma, 471 
Lentigo, 404 

maligna, 120, 405 
Leontiasis, 407 
Lepothrix, 406 
Lepra, diagnosis, 414 



INDEX 



763 



Lepra, etiology, 413 

pathology, 413 
prognosis, 417 
symptoms, 407 
treatment, 415 
alphos, 545 
Arabum, 407 
Grecorum, 407, 545 
Leprosy, 407 

Lombardian, 503 
Leptus autumn alis, 493 
Leucasmus, 729 
Leucoderma, 729 
Leucokeratosis buccalis, 418 
Leuconychia, 417 
Leucopathia, 729 
unguium, 417 
Leucoplakia, 417 
Leukemia cutis, 419 
Lichen annularis, 345 
circinatus, 611 
hypertrophicus, 429 
menti, 620 
nitidus, 422 
obtusus, 423, 429 
corneous, 423 
pilaris, 399, 424 
planus, diagnosis, 430 
etiology, 429 
pathology, 430 
prognosis, 432 
symptoms, 425 
treatment, 430 
sclerosus et atrophicus, 432 
ruber acuminatus, 433, 524 
moniliformis, 428 
planus, 425 
scrofulosorum, 433 
scrofulosus, 433 
simplex, 221 
spinulosus, 424 
tropicus, 457 
urticatus, 715 
variegatus, 492 
verrucosus, 429 
Lichenification, 420 
Lineae albicantes, 126 
Lines, symptomatic, 125 
Linsennecke, 404 
Linsenmal, 473 

Liodermia essentialis c. melanosi 
et telangiectasia, 120 



Lipoma, 435 

Liquid air, 49 

Liquor picis alkalinus, 748 

Liver spot, 140 

Lotio alba, 747 

plumbi et opii, 747 
Lousiness, 495 
Lues, 630 

Lupus ervthemateux disseminee, 
328 
erythematodes, 435 
erythematosus, diagnosis, 
440 
etiology, 439 
pathology, 439 
prognosis, 443 
symptoms, 435 
treatment, 440 
exulcerans, 446 
follicularis disseminatus, 447 
hypertrophicus, 446 
lymphaticus, 455 
miliaris, 447 
pernio, 444 
papillomatosus, 446 
sclereux, 707 
sebaceus, 435 
superficialis, 435 
verrucosus, 446, 707 
vulgaris, diagnosis, 449 
etiology, 447 
pathology, 448 
prognosis, 455 
symptoms, 444 
treatment, 449 
Lustseuche, 631 
Lymphadenie cutanee, 467 
Lymphangiectasis, 455 
Lymphangietodes, 455 
Lymphangioma, 455 

tuberosum multiplex, 457 
Lymphangioma, 472 
Lymphatics, 21 
L3'inphodermia perniciosa, 467 
Lymphorrhagica pachydermia, 
455 



M 

Macule cerulese, 498 
Macule, the, 29 



764 



INDEX 



Macule, symptomatic, 125 
Madura-foot, 336 
Mai de la rosa, 503 

de los pintos, 517 

roxo, 503 
Malingering, 176 
Malleus, 285 
Malum venereum, 630 
Mamillaris maligna, 486 
Marsden's paste, 746 
Masern, 464 
Mask, 140 
Massage, 50 
Measles, 464 

German, 581 
Melanhidrosis, 144 
Melanoderma, 140 
Melanosarcoma, 585 
Melanosis lenticularis, progres- 
siva, 120 
Melasma, 140 
Melitagra, 245 
Melung, 457 
Mentagra, 620 
Merkel's touch cells, 23 
Microsporon anomeon, 523 

Audouini, 695 

furfur, 148 

minutissimum, 311 

tropicum, 149 
Middlesex Hospital paste, 747 
Miliaria, 457 

crystallina, 458 
Miliary fever, 459 
Milium, 460 
Milk crust, 245, 258 
Milzbrand, 570 
Mitesser, 154 
Mixed treatment, 744 
Mole, pigmentary, 473 
Molluscum cholesterique, 732 

contagiosum, 461 

epitheliale, 461 

fibrosum, 325 

pendulum, 325 

sebaceum, 461 

sessile, 461 

simplex, 325 . 

verrucosum, 461 
Monilethrix, 119 
Morbilli, 464 
Morbus elephas, 264 



Morbus Gallicus, 630 

Hispanicus, 630 

Indicus, 631 

Italicus, 630 

maculosus Werlhoffii, 566 

Neapolitanus, 630 

pedicularis, 495 
Morphea, 603 
Morpion, 492 
Morvan's disease, 466, 680 
Morve, 285 
Mosquitoe-bites, 493 
Moth-patch, 140 
Mother's mark, 473 
Mower's mite, 493 
Mucous layer, 19 

patch, 640 
Myasis externa dermatosa, 466 
Mycetoma, 336 
Mycosis frambcesiodes, 197 

fungoides, diagnosis, 470 
etiology, 469 
pathology, 469 
prognosis, 471 
symptoms, 468 
treatment, 470 

microsporina, 146 
Myoma, 471 

Myxadenitis labialis, 140 
Myxedema, 472 



N 



Nails, anatomy of, 24 

atrophy of, 119 

ingrowing, 494 
Nectator Americanus, 714 
Neoplasm, inflammatory fungoid, 

467 
Neuralgia of skin, 161 
Neurofibroma, 325 
Neuroma cutis, 473 
Nerves, 22 
Nesselausschlag, 715 
Nesselsuch, 715 
Nettlerash, 715 
Nevus anemicus, 473 

araneus, 681 

flammeus, 477 

lipomatodes, 473 

lupus, 112 



IXDEX 



765 



Nevus, nerve, -190 

pigmentosum, 473 

pilosus, 477 

sanguineus, 477 

simplex, 477 

spilus, 473 

tuberosus, 477 

unius lateris, 490 

vascularis, 477 

vasculosis, 477 

venous, 477 

verrucosus, 473 
Xodule, 31 

Xodules, ephemeral cutaneous, 
481 

ervthematous of arthritis, 
481 

rheumatismal, 481 

subcutaneous rheumatic, 481 
Xodulus laqueatus, 482 
Xoli me tangere, 272, 444 
Nomenclature, 53 



(Edema, acute idiopathic, 482 

angioneurotic, 482 

cutis, acute circumscribed, 
482 

neonatorum, 483 
Oidiomycosis, 483 
Onychauxis, 484 
Onychia, 485 
Onychitis, 485 
Onychogryphosis, 484 
Onychomycosis, 486, 691 
Ophiosis, 100 
Oriental sore, 88 
Osmidrosis, 128 
Osteosis cutis, 486 



Pachydermatocele, 213 
Pachydermia, 264 
Paget 's disease, 486 
Pain, 40 

Panaris nerveux, 489 
Panne hepatique, 140 
Panniculus adiposus, 21 



Papillargeschwiilste, Beer- 

schwamahnliche, 467 
Papilloma, 489 

area elevatum, 490 

lineare, 490 

neuroticum, 490 
: Papule, 30 
i Parakeratosis scutularis, 491 

variegata, 491 
Parangi, 736 
Parasitic diseases, 492 
Paronychia, 494 
Pedicularia, 495 
Pediculosis, diagnosis, 500 - 

etiology, 498 

symptoms, 495 

treatment, 501 
Pelade, 100 

Peliosis rheumatica, 567 
Pellagra, 503 

Pemphigus, diagnosis, 510 
etiology, 509 
pathology, 510 
prognosis, 512 
symptoms, 505 
treatment, 511 

acutus contagiosus, 508 

a petit es bulles, 180 

circinatus, 180 

foliaceous, 508 

grangenosus, 179 

neonatorum, 507 

pruriginosus, 180, 508 

vegetans, 507 
Perifolliculitis cicatrisans, 330 

suppurativa, 513 
Perisarcoma, 571 
Perleche, 515 
Pernio, 168 
Phagmesis, 516 
Phlegmasia Malabarica, 264 
Phthiriasis, 495 
Phylzaci agria, 216 
Phvto-alopecia, 100 
Pian, 736 

ruboide, 197 
Piebald-skin, 729 
Piedra, 516 
Pigmentflecken, 140 
Pigmentmal, 473 
Pimple, 62 
Pint a, 517 



766 



INDEX 



Pityriasis, 609 

alba atrophicans, 518 

capitis, 518 

lichenoides chronica, 520 

maculata et circinata, 521 

nigricans, 143 

parasitaire, 146 

pilaris, 399 

rosea, diagnosis, 523 
etiology, 522 
pathology, 523 
symptoms, 521 
treatment, 524 

rubra, 169 

pilaris, diagnosis, 526 
etiology, 526 
pathology, 526 
symptoms, 524 
treatment, 527 

simplex, 518 

steatodes, 518 

tabescentium, 527 

versicolor, 146 
Plica neuropathica, 529 

polonica, 527 
Podelcoma, 336 
Poils accidentels, 364 
Poison ivy eruption, 208 
Poliosis, 130 
Poliothrix, 130 
Polyidrosis, 360 
Polypapilloma tropicum, 736 
Polytrichia, 364 
Pompholyx, 505, 529 
Porcellanfriessel, 715 
Porokeratosis, 531 
Porrigo, 245 

contagiosa, 382 

decalvans, 100 

favosa, 313 

furfurans, 687 

lavalis, 313 

lupenosa, 313 

nodularis, 424 

scutulata, 313 

true, 313 
Porrigophyta, 313 
Port-wine mark, 477 
Pox, 631 
Prairie itch, 534 
Prickly heat, 457 
Proud flesh, 127, 347 



Prurigo, 534 
Pruritus, 39 

cutaneous, diagnosis, 540 
etiology, 539 
prognosis, 544 
symptoms, 538 
treatment, 541 
Pseudo-alopecia area, 329 

atrophicans, 329 
Pseudo-erysipelas, 544 
Pseudo-leucemia cutis, 544 

lupus, 163 
Psora, 545 
Psoriasis, buccalis, 418 

diagnosis, 553 

etiology, 551 

pathology, 553 

prognosis, 564 

symptoms, 545 

treatment, 556 
Psorospermosis, 395 
Pterygium, 564 
Pulex irritans, 493 

penetrans, 493 
Purpura, diagnosis, 569 

etiology, 568 

pathology, 569 

prognosis, 570 

symptoms, 564 

treatment, 569 
Pustula maligna, 570 
Pustule, 33 
Pyodermatitis vegetans, 207 



Q 

Quinquaud's disease, 332 
Quirica, 517 



Radiotherapy, 43 
Radium, 47 
Ray fungus, 85 
Raynaud's disease, 178 
Recklinghausen's disease, 325 
Red gum, 458 
Rete malpighii, 19 
Rheumatism of skin, 61 
Rhigolene, 48 



INDEX 



767 



Rhinophyma, 571, 575 

Rhinoscleroma, 571 

Rhus poisoning, 208 

Ringskurv, 687 

Ringworm, 685, 687, 691 
crusted, 313 
honeycomb, 313 
Polish, 527 
Tokelan, 682 

Risipola, 286 

lombarda, 503 

Ritter's disease, 175 

Rodent ulcer, 276 

Rogna grossa, 216 

Rosacea, diagnosis, 577 
etiology, 576 
pathology, 577 
prognosis, 581 
symptoms, 574 
treatment, 578 

Rose, la, 286 
rash, 293 

Roseola, 297 

pityriaca, 521 

Rotheln, 582 

Rothlauf, 286 

Rotz, 285 

RubeUa, 581 

Rubeola, 464 

Run-around, 494 

Rupia, 651 

escharotica, 179 



S 



St. Anthony's fire, 286 

Salt rheum, 218 

Salsfluss, 218 

Sarcocele of Egyptians, 264 

Sarcoid, 345, 582 

Sarcoma cutis, multiple, 467 

diagnosis, 589 

etiology, 588 

pathology, 588 

prognosis, 590 

symptoms, 585 

treatment, 590 
Sarcomatosis generalis, 467 
Sarcopsylla penetrans, 494 
Satyriasis, 407 
Sauriasis, 375 



Savill's disease, 174 
Scabies, diagnosis, 596 

etiology, 592 

pathology, 593 

prognosis, 598 

symptoms, 591 

treatment, 596 
Scald, 218 
Scale, 34 
Scall, 218, 245 

head, 245, 313 
Scar, hypertrophied, 392 

keloidal, 392 
Scarf skin, 17 
Scarlatina, 598 
Scarlet fever, 598 
Schmeerfluss, 609 
Schuppenflechte, 545 
Schweissflecht, 457 
Scissura pilorum, 115 
Sclerem der Neugeboren, 599 
j Sclerema adultorum, 6011 

neonatorum, 599 
Scleriasis, 601 
Sclerodactylie, 603 
Scleroderma, 601 

neonatorum, 599 
Scleroma adultorum, 601 
Sclerostenosis, 601 
Scrofulide boutonneuse, 534 

erythemateuse, 435 

tuberculeuse, 444 
Scrofuloderma, 606 

ulcerative, 467 

verrucosum, 707 
Scurvy, land, 566 
Sebaceous glands, 25 
Seborrhagia, 609 
Seborrhea, 609 

congestiva, 435 

corporis, 201, 611 

nigricans, 143 

oleosa, 609, 610 

sicca, 518, 519, 611 
Shingles, 738 
Siderosis, 617 
Skin > anatomy of, 17 

bloodvessels of, 21 

cancer, 137, 272 

elastic, 213 

glossy, 124 

lesions of, 29 



768 



INDEX 



Skin, loose, 213 

lymphatics of, 21 

muscles of, 27 

nerves of, 22 

neuralgia of, 161 

physiology of, 27 

rheumatism of, 161 
Smallpox, 723 

Soap, superoxide of soda, 753 
Sommersprossen, 404 
Spargosis, 264 
Spedalskhed, 407 
Sphaceloderma, 177 
Spider cancer, 681 
Spilosis poliosis, 131 
Spiradenoma, 87 
Spirocheta pallida, 658 
Spoon nails, 403 
Sporotrichosis hypodermica, 617 
Spotted sickness, 517 
Startin's mixture, 745 
Stearrhea, 609 

nigricans, 143 
Steatoma, 160 
Steatorrhea, 609 
Stigmata, bleeding, 350 
Stone-pock, 62 
Stratum corneum, 19 

granulosum, 19 

mucosum, 19 
Streaks, idiopathic, 125 
Streptococcus of Fehleisen, 288 
Strophulus, 457 

albidus, 460 

prurigineux, 534 
Sudamina, 457 
Sudatoria, 360 
Sudor urinosis, 714 
Sulphur cream, 206 
Summer eruption, 358 
Sunburn, 167 
Sweat, blue, 144 

glands, 26 

green, 145 

yellow, 145 

red, 145 
Sweating, excessive, 360 

sickness, 459 
Swelling, giant, 482 

periodic, 482 
Svcosis, diagnosis, 624 
etiology, 623 



Sycosis, pathology, 624 

prognosis, 630 

symptoms, 620 

treatment, 626 
barbae, 620 
capillitii, 197 
frambesia, 197 
menti, 620 
non-parasitica, 620 
parasitica, 691 
Syphilis, diagnosis of erythema- 
tous, 636 

general, 657 

gummatous, 654 

papular, 642 

pustular, 644 

pustulocrustaceous, 652 

squamous, 650 

tubercular, 647 

ulcerative, 655 
etiology, 658 
hereditary, 660 
pathology, 659 
prognosis, 679 
secondary, 635 
symptoms, 635 
tertiary, 644 
treatment, 665 
Syringocystadenome, 284 
Syringomyelia, 680 



Tache de feu, 477 

hepatique, 140 

ombree, 498 

vasculaire, 477 
Tanne, 154 
Tattoo, 680 
Teigne du pauvre, 313 

faveuse, 313 

pelade, 100 

tondante, 687 

tonsurans, 687 
Telangiectasis, 681 
Tetter, 218 
Therapeutic notes, 41 
Tinctura saponis viridis, 750 
Tinea albigena, 686 

amiantacea, 609 



INDEX 



769 



Tinea asbestina, 609 

barbae, 691 

circinata, 685 

decalvans, 100 

favosa, 313 

ficosa, 313 

imbricata, 682 

kerion, 402 

lupinosa, 313 

maligna, 313 

nodosa, 516, 684 

sycosis, 691 

tondens, 687 

tonsurans, 687 

vera, 313 

versicolor, 146 
Tinna, 517 
Tongue, black, 127 

hairy, 127 
Toxituberculides papulo necro- 

tiques, 328 
Trepenoma pallida, 658 
Trichauxis, 364 
Trichiasis, 684 
Trichoclasia, 116 
Trichoma, 527 
Trichomycosis capillitii, 402 

favosa, 313 

nodosa, 406, 516 

palmellina, 406 
Trichonosis cana, 131 

discolor, 131 

poliosis, 131 
Trichophytosis, etiology, 693 
pathology, 694 
prognosis, 704 
svmptoms, 685 
treatment, 696 

barbae, diagnosis, 691 
symptoms, 691 

capitis, diagnosis, 690 
symptoms, 687 

corporis, diagnosis, 687 
symptoms, 685 

unguium, diagnosis, 693 
symptoms, 693 
Trichoptylose, 116 
Trichorrhexis nodosa, 116 
Trichosis hirsuties, 364 

plica, 527 
Tropical big leg, 264 
Trypanosomiasis, 705 
49 



Tubercle, the, 31 

anatomical, 707 
Tuberculosis cutis, 706 
orificialis, 706 

miliary, 706 

ulcerosa, 706 

verrucosa cutis, 707 
Tuberculum sebaceum, 460 
Tumor, the, 34 

itching, 424 

multiple fungoid, 467 
Tyloma, 130 
Tylosis, 130 

linguae, 418 

palmse et plantae, 398 



Ulcer, the, 35, 710 

tropical phagedenic, 712 
Ulcus grave, 336 
perforans, 512 
rodens, 276 
Ulerythema, 435, 712 
acneiforme, 714 
centrifigum, 435 
ophyroginis, 713 
sycosiforme, 329, 623, 702 
Uncinarial dermatitis, 714 
Uridrosis, 714 
Urticaria, diagnosis, 718 
etiology, 717 
pathology, 717 
prognosis, 720 
symptoms, 715 
treatment, 719 
pigmentosa, 721 



Vaccine therapy, 50 
Vaccinia, 722 
Vagabond's disease, 496 
Varicella, 723 

gangrenosa, 179 
Variola, 723 
Varioloid, 724 
Veld sore, 724 
Verole, 631 
Verruca, 724 



770 



INDEX 



Verruca necrogenica, 707 
Verrue, 724 

telangiectasique, 110 
Verruga, 736 

peruana, 728 
Vesicle, the, 32 
Vienna paste, 746 
Vitiligo, 729 

capitis, 100 
Vitiligoidea, 732 
Vleminckx's' solution, 748 



W 

Wart, 724 

postmortem, 707 
telangiectatic, 110 

Warze, 724 

Washleather-skin, 731 

Weichselzopf, 527 

Wen, 160 

Wheal, the, 31 

Whitlow, 485, 494 
melanotic, 586 

Wildfire, 286 

Wilkinson's ointment, 752 

Wood-tick, 493 

Wundrose, 286 



X-ray, 43 

dermatitis, 199 
Xanthelasma, 732 
Xanthelasmoidea, 721 
Xanthoma, 732 

diabeticorum, 735 
Xeroderma, 375 

ichthyodes, 375 

pigmentosum, 120 
Xerodermic pilaire, 399 
Xerosis, 114 



Yaws, 736 



Zona, 738 

Zoster, diagnosis, 741 
etiology, 739 
pathology, 740 
prognosis, 742 
symptoms, 738 
treatment, 741 



